Provider Demographics
NPI:1295214914
Name:MANGIAFICO, CAROLYN (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MANGIAFICO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1401
Mailing Address - Country:US
Mailing Address - Phone:860-575-1671
Mailing Address - Fax:
Practice Address - Street 1:769 NEWFIELD ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-1846
Practice Address - Country:US
Practice Address - Phone:860-575-1671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4009104100000X, 1041C0700X
CT0040091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPENDINGMedicaid