Provider Demographics
NPI:1164142212
Name:MANGRUM, DENISE MICHELLE (DT)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MICHELLE
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 RICH RD
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1630
Mailing Address - Country:US
Mailing Address - Phone:773-971-2230
Mailing Address - Fax:
Practice Address - Street 1:252 RICH RD
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1630
Practice Address - Country:US
Practice Address - Phone:773-971-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist