Provider Demographics
NPI:1174308092
Name:MANGAN, OLIVIA (OTR/L)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MANGAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 STARLIT DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3515
Mailing Address - Country:US
Mailing Address - Phone:631-806-1859
Mailing Address - Fax:
Practice Address - Street 1:3559 MERRICK RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-2833
Practice Address - Country:US
Practice Address - Phone:516-639-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028301225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist