Provider Demographics
NPI:1679030035
Name:MANGIN, ATLANTIDE (APCC)
Entity Type:Individual
Prefix:MRS
First Name:ATLANTIDE
Middle Name:
Last Name:MANGIN
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 E ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2024
Mailing Address - Country:US
Mailing Address - Phone:619-234-3346
Mailing Address - Fax:619-234-3357
Practice Address - Street 1:2410 E ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2024
Practice Address - Country:US
Practice Address - Phone:619-234-3346
Practice Address - Fax:619-234-3357
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5575Medicaid