Provider Demographics
NPI:1811305295
Name:MANGANIELLO, LISA (LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MANGANIELLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E NEWTON ST
Mailing Address - Street 2:BOSTON MEDICAL CENTER, SOLOMON CARTER FULLER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2340
Mailing Address - Country:US
Mailing Address - Phone:617-414-4759
Mailing Address - Fax:
Practice Address - Street 1:85 E NEWTON ST
Practice Address - Street 2:BOSTON MEDICAL CENTER, SOLOMON CARTER FULLER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2340
Practice Address - Country:US
Practice Address - Phone:617-414-4759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1168271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical