Provider Demographics
NPI:1053625087
Name:MANGINO, MELISSA (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:MANGINO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-2905
Mailing Address - Country:US
Mailing Address - Phone:585-409-8369
Mailing Address - Fax:
Practice Address - Street 1:80 MUNSON ST
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:NY
Practice Address - Zip Code:14482-8933
Practice Address - Country:US
Practice Address - Phone:585-344-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020282-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist