Provider Demographics
NPI:1588890602
Name:MANGANELLO, PAMELA MARY
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARY
Last Name:MANGANELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ROSALIE PL
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2977
Mailing Address - Country:US
Mailing Address - Phone:303-523-2727
Mailing Address - Fax:
Practice Address - Street 1:15 ROSALIE PL
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2977
Practice Address - Country:US
Practice Address - Phone:303-523-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10650225X00000X
NY020598-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020598-1OtherLICENSE
CA10650OtherOCCUPATIONAL THERAPIST