Provider Demographics
NPI:1497375026
Name:MANGIPUDI, NEERAV
Entity Type:Individual
Prefix:
First Name:NEERAV
Middle Name:
Last Name:MANGIPUDI
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 1:3050 SATURN ST
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6221
Mailing Address - Country:US
Mailing Address - Phone:361-563-7518
Mailing Address - Fax:
Practice Address - Street 1:3050 SATURN ST
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6221
Practice Address - Country:US
Practice Address - Phone:361-563-7518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst