Provider Demographics
NPI:1255495834
Name:MANGIN, BETH K (LCPC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:K
Last Name:MANGIN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1N121 COUNTY FARM RD STE 220
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-2034
Mailing Address - Country:US
Mailing Address - Phone:630-488-5846
Mailing Address - Fax:
Practice Address - Street 1:1N121 COUNTY FARM RD STE 220
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-2034
Practice Address - Country:US
Practice Address - Phone:603-488-5846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1800006337101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180006337OtherSTATE LICENSE
IL02215643OtherBLUE CROSS