Provider Demographics
NPI:1942497011
Name:DIMANGO, KATRINA ELIZABETH (BA)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:ELIZABETH
Last Name:DIMANGO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:248-668-8650
Mailing Address - Fax:248-668-8651
Practice Address - Street 1:41100 FOX RUN
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-4804
Practice Address - Country:US
Practice Address - Phone:248-668-8650
Practice Address - Fax:248-668-8651
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010912271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid