Provider Demographics
NPI:1043886401
Name:MANGANO, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:MANGANO
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 1:13245 OTTENBECKER RD
Mailing Address - Street 2:
Mailing Address - City:LAWTONS
Mailing Address - State:NY
Mailing Address - Zip Code:14091-9791
Mailing Address - Country:US
Mailing Address - Phone:716-713-2609
Mailing Address - Fax:
Practice Address - Street 1:393 NORTH ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-9652
Practice Address - Country:US
Practice Address - Phone:716-592-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NY032262-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist