Provider Demographics
NPI:1619145075
Name:MANGANIELLO, KRISTA BAILEY (MA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:BAILEY
Last Name:MANGANIELLO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8297 WESTCOTT SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-7682
Mailing Address - Country:US
Mailing Address - Phone:407-595-1619
Mailing Address - Fax:
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-272-2878
Practice Address - Fax:813-272-3766
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 9752101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health