Provider Demographics
NPI:1164530002
Name:MANGAN, KEVIN
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MANGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 NEW SCOTLAND ROAD
Practice Address - Street 2:SPEECH PATHOLOGY AND AUDIOLOGY DEPARTMENT
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159
Practice Address - Country:US
Practice Address - Phone:518-475-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4570231H00000X
NY001613231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA027064Medicare ID - Type Unspecified