Provider Demographics
NPI:1114297678
Name:S MANGNALL-HARRIS, PSYD, PMHNP, LLC
Entity Type:Organization
Organization Name:S MANGNALL-HARRIS, PSYD, PMHNP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:Z
Authorized Official - Last Name:MANGNALL-HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:541-289-0955
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-0154
Mailing Address - Country:US
Mailing Address - Phone:541-289-0955
Mailing Address - Fax:541-289-0956
Practice Address - Street 1:955 W ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-1591
Practice Address - Country:US
Practice Address - Phone:541-289-0955
Practice Address - Fax:541-289-0956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150002NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty