Provider Demographics
NPI:1710490628
Name:MASSENGALE, CAROLYN D (171M00000X)
Entity Type:Individual
Prefix:MR
First Name:CAROLYN
Middle Name:D
Last Name:MASSENGALE
Suffix:
Gender:F
Credentials:171M00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1384 W 117TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3011
Mailing Address - Country:US
Mailing Address - Phone:216-221-7588
Mailing Address - Fax:216-221-7915
Practice Address - Street 1:1384 W 117TH ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3011
Practice Address - Country:US
Practice Address - Phone:216-221-7588
Practice Address - Fax:216-221-7915
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator