Provider Demographics
NPI:1003997073
Name:MANGANIELLO, JAMES A (EDD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:MANGANIELLO
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:MA
Mailing Address - Zip Code:01834-1001
Mailing Address - Country:US
Mailing Address - Phone:978-979-4480
Mailing Address - Fax:978-374-7557
Practice Address - Street 1:33 CONOMO POINT RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MA
Practice Address - Zip Code:01929-1040
Practice Address - Country:US
Practice Address - Phone:978-979-4480
Practice Address - Fax:978-768-2589
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1690103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01854Medicare ID - Type Unspecified