Provider Demographics
NPI:1144676974
Name:MANGIAPANE, MATTHEW JON (LMFT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JON
Last Name:MANGIAPANE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1831
Mailing Address - Country:US
Mailing Address - Phone:516-527-0947
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS AVE UNIT 41
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-8002
Practice Address - Country:US
Practice Address - Phone:631-604-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001010OtherNYS LMFT