Provider Demographics
NPI:1952319212
Name:MAMANGON, MARYJOYCE (PT)
Entity Type:Individual
Prefix:
First Name:MARYJOYCE
Middle Name:
Last Name:MAMANGON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MANIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977-6420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 PERLMAN DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5281
Practice Address - Country:US
Practice Address - Phone:845-425-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021842-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ05V52Medicare ID - Type Unspecified