Provider Demographics
NPI:1376653774
Name:MANGINE, JOSEPH D (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:D
Last Name:MANGINE
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 1:5040 FOREST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8167
Mailing Address - Country:US
Mailing Address - Phone:413-218-1105
Mailing Address - Fax:
Practice Address - Street 1:571 HIGH ST STE 12
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4132
Practice Address - Country:US
Practice Address - Phone:413-218-1105
Practice Address - Fax:614-591-0710
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.7370103TC1900X
OH7370103TC1900X
MA7134103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0174857Medicaid
MAW50660Medicare ID - Type Unspecified