Provider Demographics
NPI:1578103164
Name:MANGINI, CORY JAVON
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:JAVON
Last Name:MANGINI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13102 TITLEIST DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-2410
Mailing Address - Country:US
Mailing Address - Phone:352-586-1052
Mailing Address - Fax:
Practice Address - Street 1:9405 BARNSTEAD LN
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-4302
Practice Address - Country:US
Practice Address - Phone:727-967-2809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105713200Medicaid