Provider Demographics
NPI:1699007773
Name:MANGIONE, KELLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MANGIONE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 TILDEN AVE
Mailing Address - Street 2:PO BOX 1000
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-3613
Mailing Address - Country:US
Mailing Address - Phone:315-737-2462
Mailing Address - Fax:
Practice Address - Street 1:2050 TILDEN AVE
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-3613
Practice Address - Country:US
Practice Address - Phone:315-737-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01815443Medicaid
NY00313539Medicaid
NY335475Medicare Oscar/Certification
NY334526Medicare Oscar/Certification