Provider Demographics
NPI:1245749548
Name:MANGOSH, MATTHEW (LSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MANGOSH
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 N ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2129
Mailing Address - Country:US
Mailing Address - Phone:440-488-8684
Mailing Address - Fax:
Practice Address - Street 1:13201 GRANGER RD STE 8
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-1979
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2405088-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker