Provider Demographics
NPI:1063705101
Name:MANGIAMELI, ANNETTE GINA (PHD)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:GINA
Last Name:MANGIAMELI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:GINA
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4349 JEKER DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-3571
Mailing Address - Country:US
Mailing Address - Phone:619-762-8909
Mailing Address - Fax:
Practice Address - Street 1:4349 JEKER DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-3571
Practice Address - Country:US
Practice Address - Phone:619-762-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17997103TC0700X
TX34289103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2843021Medicaid