Provider Demographics
NPI:1366953655
Name:MANGUAL-MARQUEZ, MICHAEL JEROME
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEROME
Last Name:MANGUAL-MARQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 JANIE LN
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1304
Mailing Address - Country:US
Mailing Address - Phone:732-770-0734
Mailing Address - Fax:
Practice Address - Street 1:10 PARSONAGE RD STE 318
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2429
Practice Address - Country:US
Practice Address - Phone:732-204-1635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician