Provider Demographics
NPI:1053068676
Name:MANGANELLO, SARA LYNN
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:LYNN
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 1:11 CHAPLIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3208
Mailing Address - Country:US
Mailing Address - Phone:860-970-4173
Mailing Address - Fax:
Practice Address - Street 1:11 CHAPLIN ST
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3208
Practice Address - Country:US
Practice Address - Phone:860-970-4173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT102375306Medicaid