Provider Demographics
NPI:1972192268
Name:MANGES, DEA NICOLE
Entity Type:Individual
Prefix:
First Name:DEA
Middle Name:NICOLE
Last Name:MANGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-3144
Mailing Address - Country:US
Mailing Address - Phone:440-308-8665
Mailing Address - Fax:
Practice Address - Street 1:347 MIDWAY BLVD STE 210
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2496
Practice Address - Country:US
Practice Address - Phone:440-324-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2309988104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker