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General NPI Number Information
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NPI Number | 1245749548
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Entity Type | Individual
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Provider Name | MATTHEW MANGOSH LISW-S
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Gender | Male
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Dates
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Enumeration Date | 09/29/2017
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Last Update Date | 06/30/2025
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Provider Practice Location Address
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Address Line | 22001 FAIRMOUNT BLVD
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City | CLEVELAND
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State | OH
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Zip | 44118-4819
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Country | US
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Telephone | 216-932-2800
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Fax |
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Provider Business Mailing Address
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Address Line | 686 N ELMWOOD AVE
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City | WICKLIFFE
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State | OH
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Zip | 44092-2129
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Country | US
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Telephone | 440-488-8684
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | I.2405088-SUPV
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License Number State | OH
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