Provider Demographics
NPI:1609558501
Name:MANGIARDI, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MANGIARDI
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 1:530 OAK GROVE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3255
Mailing Address - Country:US
Mailing Address - Phone:650-395-7299
Mailing Address - Fax:
Practice Address - Street 1:530 OAK GROVE AVE STE 104
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-3255
Practice Address - Country:US
Practice Address - Phone:650-395-7299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10881101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health