Provider Demographics
NPI:1366508350
Name:MANGUM, CARL BUFORD (EDD, LCSW)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:BUFORD
Last Name:MANGUM
Suffix:
Gender:M
Credentials:EDD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7224 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2852
Mailing Address - Country:US
Mailing Address - Phone:985-868-2799
Mailing Address - Fax:985-868-2766
Practice Address - Street 1:7224 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2852
Practice Address - Country:US
Practice Address - Phone:985-868-2799
Practice Address - Fax:985-868-2766
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical