=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558599563
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE MANGANO SMART OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2009
-----------------------------------------------------
Last Update Date | 07/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 LOOMIS ST APARMENT 1
-----------------------------------------------------
City | MONTPELIER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05602-2438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-232-4922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 LOOMIS ST
-----------------------------------------------------
City | MONTPELIER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05602-2438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-232-4922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 072.0000470
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------