Provider Demographics
NPI:1114439072
Name:MANCINI, RICHARD JOHN (BC-HIS, ACA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:MANCINI
Suffix:
Gender:M
Credentials:BC-HIS, ACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2004
Mailing Address - Country:US
Mailing Address - Phone:860-643-4413
Mailing Address - Fax:860-643-4436
Practice Address - Street 1:240 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2004
Practice Address - Country:US
Practice Address - Phone:860-643-4413
Practice Address - Fax:860-643-4436
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT352237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1386769453Medicaid