Provider Demographics
NPI:1578838165
Name:MANGOLD, SHELLY (CADC II)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:MANGOLD
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 PRESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4453
Mailing Address - Country:US
Mailing Address - Phone:951-955-1454
Mailing Address - Fax:
Practice Address - Street 1:3525 PRESLEY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4453
Practice Address - Country:US
Practice Address - Phone:951-941-9672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)