Provider Demographics
NPI:1427538180
Name:MANGRAVITO, SAMANTHA LYNNE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNNE
Last Name:MANGRAVITO
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 1:74 HASTINGS AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2578
Mailing Address - Country:US
Mailing Address - Phone:862-262-3394
Mailing Address - Fax:
Practice Address - Street 1:74 HASTINGS AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2578
Practice Address - Country:US
Practice Address - Phone:862-262-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00841400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist