Provider Demographics
NPI:1235418013
Name:MANGOLD, HEATHER M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:MANGOLD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WINDMILL RD
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-2121
Mailing Address - Country:US
Mailing Address - Phone:860-871-7749
Mailing Address - Fax:
Practice Address - Street 1:26 WINDMILL RD
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-2121
Practice Address - Country:US
Practice Address - Phone:860-871-7749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2011-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist