Provider Demographics
NPI:1043359516
Name:MANGANARO, JOHN (LICSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MANGANARO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:MANGANARO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:88 WEBB ST
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02188-2720
Mailing Address - Country:US
Mailing Address - Phone:781-337-8217
Mailing Address - Fax:
Practice Address - Street 1:62 DERBY ST
Practice Address - Street 2:SUITE 15
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-3728
Practice Address - Country:US
Practice Address - Phone:781-337-8217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020693101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP06020Medicare ID - Type Unspecified