Provider Demographics
NPI:1003435553
Name:MANGRUM, SAVANNAH
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 N KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2138 FAWNS CREEK XING
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-1207
Practice Address - Country:US
Practice Address - Phone:615-866-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician