Provider Demographics
NPI:1780037747
Name:MANGIAMELI, JOHNMARK (MSW)
Entity type:Individual
Prefix:
First Name:JOHNMARK
Middle Name:
Last Name:MANGIAMELI
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MCKINLEY RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2131
Mailing Address - Country:US
Mailing Address - Phone:845-282-9833
Mailing Address - Fax:
Practice Address - Street 1:21 MCKINLEY RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2131
Practice Address - Country:US
Practice Address - Phone:845-282-9833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1211851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical