Provider Demographics
NPI:1639925191
Name:MANGANO MACK, DOMINIQUE MICHELLE (LAC)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MICHELLE
Last Name:MANGANO MACK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19819 W MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-5426
Mailing Address - Country:US
Mailing Address - Phone:708-209-9952
Mailing Address - Fax:
Practice Address - Street 1:13471 W CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2713
Practice Address - Country:US
Practice Address - Phone:480-964-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22735101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health