Provider Demographics
NPI:1205394731
Name:MANGENA, SEMKHELE
Entity Type:Individual
Prefix:
First Name:SEMKHELE
Middle Name:
Last Name:MANGENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4876 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1022
Mailing Address - Country:US
Mailing Address - Phone:574-904-4892
Mailing Address - Fax:
Practice Address - Street 1:4876 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1022
Practice Address - Country:US
Practice Address - Phone:574-904-4892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-18-33454103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst