Provider Demographics
NPI:1770859415
Name:MANGUAL, GEORGE HERMAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:HERMAN
Last Name:MANGUAL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:
Other - Last Name:MANGUAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 80561
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92138-0561
Mailing Address - Country:US
Mailing Address - Phone:619-534-1070
Mailing Address - Fax:
Practice Address - Street 1:SUBSTANCE ABUSE COUNSELING CTR
Practice Address - Street 2:4025 TRIPOLI AVENUE, BLDG 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5000
Practice Address - Country:US
Practice Address - Phone:619-524-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2400101Y00000X
CA274191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor