Provider Demographics
NPI:1932677671
Name:MAYANGAO, LEA ANGELICA (PHYSICAL THERAPY)
Entity Type:Individual
Prefix:MISS
First Name:LEA ANGELICA
Middle Name:
Last Name:MAYANGAO
Suffix:
Gender:F
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MAIN TER
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4012
Mailing Address - Country:US
Mailing Address - Phone:551-232-7495
Mailing Address - Fax:
Practice Address - Street 1:98 E 4TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9001
Practice Address - Country:US
Practice Address - Phone:646-230-8190
Practice Address - Fax:646-230-8185
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043284225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJM09534507453922OtherSTATE ID