Provider Demographics
NPI:1154455822
Name:MANGUM, TANYA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:MARIE
Last Name:MANGUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 GEER RD
Mailing Address - Street 2:STE. 120
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2454
Mailing Address - Country:US
Mailing Address - Phone:209-664-8044
Mailing Address - Fax:209-664-8036
Practice Address - Street 1:2101 GEER RD
Practice Address - Street 2:STE. 120
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2454
Practice Address - Country:US
Practice Address - Phone:209-664-8044
Practice Address - Fax:209-664-8036
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 209451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical