Provider Demographics
NPI:1124186739
Name:MANGAN, COLLEEN (CSAC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MANGAN
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W HISTORIC MITCHELL ST STE 223
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3383
Mailing Address - Country:US
Mailing Address - Phone:414-383-4455
Mailing Address - Fax:414-383-6759
Practice Address - Street 1:1225 W HISTORIC MITCHELL ST STE 223
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3383
Practice Address - Country:US
Practice Address - Phone:414-383-4455
Practice Address - Fax:414-383-6759
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI905101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39381200Medicaid