Provider Demographics
NPI:1649819699
Name:MANGO, LISA MARIE (MS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MANGO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8923 OLDHAM WAY
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33412-1110
Mailing Address - Country:US
Mailing Address - Phone:561-396-0361
Mailing Address - Fax:
Practice Address - Street 1:2222 COLONIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5309
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-21
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP3115101YM0800X, 101YA0400X
FL101YM0800X101YM0800X
101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101YM0800XMedicaid