Provider Demographics
NPI:1558599563
Name:SMART, STEPHANIE MANGANO (OTR)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MANGANO
Last Name:SMART
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-2438
Mailing Address - Country:US
Mailing Address - Phone:720-232-4922
Mailing Address - Fax:
Practice Address - Street 1:46 LOOMIS ST
Practice Address - Street 2:APARMENT 1
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2438
Practice Address - Country:US
Practice Address - Phone:702-232-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072.0000470174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT072.0000470OtherSTATE OF VERMONT LICENSE