Provider Demographics
NPI:1134487333
Name:MANGIAMELI, LYN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYN
Middle Name:J
Last Name:MANGIAMELI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 CARSON CT
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-5822
Mailing Address - Country:US
Mailing Address - Phone:415-999-6793
Mailing Address - Fax:408-736-1272
Practice Address - Street 1:320 S 3RD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-3648
Practice Address - Country:US
Practice Address - Phone:415-999-6793
Practice Address - Fax:408-736-1272
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25076103TC0700X, 103G00000X, 103TF0200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation