Provider Demographics
NPI:1063502938
Name:MANGINI, MICHAEL J JR (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MANGINI
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:99 S CANAAN RD
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06018
Mailing Address - Country:US
Mailing Address - Phone:860-824-3820
Mailing Address - Fax:860-824-5462
Practice Address - Street 1:99 S CANAAN RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018
Practice Address - Country:US
Practice Address - Phone:860-824-3820
Practice Address - Fax:860-824-5462
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4286225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
075202Medicare ID - Type Unspecified