Provider Demographics
NPI:1376949479
Name:MANGISTO, FAREED
Entity Type:Individual
Prefix:
First Name:FAREED
Middle Name:
Last Name:MANGISTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17701 SAN PASQUAL VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-5301
Mailing Address - Country:US
Mailing Address - Phone:760-233-6200
Mailing Address - Fax:760-741-4310
Practice Address - Street 1:17701 SAN PASQUAL VALLEY RD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-5301
Practice Address - Country:US
Practice Address - Phone:760-233-6200
Practice Address - Fax:760-741-4310
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113089106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist