Provider Demographics
NPI:1033623376
Name:MANGAN, LORI BETH
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:BETH
Last Name:MANGAN
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 1:103 FOX MEADOW RUN
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5504
Mailing Address - Country:US
Mailing Address - Phone:859-250-6898
Mailing Address - Fax:561-401-9196
Practice Address - Street 1:541 BUTTERMILK PIKE STE 200
Practice Address - Street 2:
Practice Address - City:CRESCENT SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:41017-1696
Practice Address - Country:US
Practice Address - Phone:859-869-2023
Practice Address - Fax:561-401-9196
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2925401041C0700X
FLSW171681041C0700X
KY2529401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical