Provider Demographics
NPI:1114780517
Name:MANGANO, MICHELLE MARIE (CAMTC #22754)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:MANGANO
Suffix:
Gender:F
Credentials:CAMTC #22754
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18582 BEACH BLVD STE 11
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2071
Mailing Address - Country:US
Mailing Address - Phone:714-964-7744
Mailing Address - Fax:714-500-0949
Practice Address - Street 1:18582 BEACH BLVD STE 11
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2071
Practice Address - Country:US
Practice Address - Phone:714-964-7744
Practice Address - Fax:714-500-0949
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22754225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist