Provider Demographics
NPI:1477391225
Name:MANGA, ATIBA
Entity type:Individual
Prefix:
First Name:ATIBA
Middle Name:
Last Name:MANGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SPARTA ST
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5149
Mailing Address - Country:US
Mailing Address - Phone:404-957-3937
Mailing Address - Fax:
Practice Address - Street 1:105 SPARTA ST
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5149
Practice Address - Country:US
Practice Address - Phone:404-957-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0000000101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool