Provider Demographics
NPI:1376246223
Name:MANGATA WELLNESS, LLC
Entity Type:Organization
Organization Name:MANGATA WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRISOSKY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CAP
Authorized Official - Phone:269-275-3508
Mailing Address - Street 1:613 SW CAMDEN AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2924
Mailing Address - Country:US
Mailing Address - Phone:772-800-5591
Mailing Address - Fax:
Practice Address - Street 1:613 SW CAMDEN AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2924
Practice Address - Country:US
Practice Address - Phone:772-800-5591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty