Provider Demographics
NPI:1629291422
Name:MANGENA, EDMORE (LPC)
Entity Type:Individual
Prefix:
First Name:EDMORE
Middle Name:
Last Name:MANGENA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:VALDEZ
Mailing Address - State:AK
Mailing Address - Zip Code:99686-0550
Mailing Address - Country:US
Mailing Address - Phone:907-835-2249
Mailing Address - Fax:907-834-1890
Practice Address - Street 1:911 MEALS AVENUE
Practice Address - Street 2:
Practice Address - City:VALDEZ
Practice Address - State:AK
Practice Address - Zip Code:99686
Practice Address - Country:US
Practice Address - Phone:078-352-8389
Practice Address - Fax:907-834-1890
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPCOP916101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional