Provider Demographics
NPI:1376126516
Name:MANGUS, IAN MICHAEL (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:MICHAEL
Last Name:MANGUS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12614 MAHOGANY ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-5181
Mailing Address - Country:US
Mailing Address - Phone:301-338-2745
Mailing Address - Fax:
Practice Address - Street 1:2720 CHARLES TOWN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-5626
Practice Address - Country:US
Practice Address - Phone:304-263-0933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02877224Z00000X
WVC2351224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant