Provider Demographics
NPI:1417737537
Name:MANGANO, SERENA
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:MANGANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 101ST ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-5704
Mailing Address - Country:US
Mailing Address - Phone:806-445-4190
Mailing Address - Fax:
Practice Address - Street 1:6500 QUAKER AVE STE D
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-5138
Practice Address - Country:US
Practice Address - Phone:806-687-5413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional