Provider Demographics
NPI:1710938923
Name:MANGIAFICO, ANTHONY DAVID (PHD, CNS)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:DAVID
Last Name:MANGIAFICO
Suffix:
Gender:M
Credentials:PHD, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2552 ALDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5306
Mailing Address - Country:US
Mailing Address - Phone:804-735-9595
Mailing Address - Fax:
Practice Address - Street 1:2552 ALDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23834-5306
Practice Address - Country:US
Practice Address - Phone:804-735-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000629101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5510571Medicaid
VA11570632OtherCAQH
VAS93594Medicare UPIN