Provider Demographics
NPI:1629483797
Name:MANGINI, MICHELLE (CMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MANGINI
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1297 ALESSANDRO DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3512
Mailing Address - Country:US
Mailing Address - Phone:530-575-0864
Mailing Address - Fax:
Practice Address - Street 1:325 E HILLCREST DR
Practice Address - Street 2:STE. 123
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5828
Practice Address - Country:US
Practice Address - Phone:805-380-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20301225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist