Provider Demographics
NPI:1538218805
Name:MANGIAFICO, KELLY ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:MANGIAFICO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:35 TOWER LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4237
Mailing Address - Country:US
Mailing Address - Phone:860-284-0048
Mailing Address - Fax:
Practice Address - Street 1:35 TOWER LN
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4237
Practice Address - Country:US
Practice Address - Phone:860-284-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CT80371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker