Provider Demographics
NPI:1720589468
Name:MANGO, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MANGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 MOUNT BLACKBURN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6618
Practice Address - Country:US
Practice Address - Phone:619-591-5740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 106S00000X
CA101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician