Provider Demographics
NPI:1194822916
Name:MANGRUM, SONJA K (MOT,OTR/L)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:K
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:MOT,OTR/L
Other - Prefix:
Other - First Name:SONJA
Other - Middle Name:K
Other - Last Name:JOHNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:15600 ACACIA RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-9313
Mailing Address - Country:US
Mailing Address - Phone:405-664-0586
Mailing Address - Fax:866-435-3297
Practice Address - Street 1:15600 ACACIA RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-9313
Practice Address - Country:US
Practice Address - Phone:405-664-0586
Practice Address - Fax:405-735-6984
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1373225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200028630AMedicaid