Provider Demographics
NPI:1184708653
Name:MANGLASS, EILEEN M (LCSW)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:M
Last Name:MANGLASS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MAIN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-5834
Mailing Address - Country:US
Mailing Address - Phone:207-653-0776
Mailing Address - Fax:
Practice Address - Street 1:79 MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5834
Practice Address - Country:US
Practice Address - Phone:207-653-0776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC97161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMAME1123Medicare ID - Type Unspecified