Provider Demographics
NPI:1396009262
Name:MANGUM, SHELLEY F (CMHC)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:F
Last Name:MANGUM
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E 9800 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3546
Mailing Address - Country:US
Mailing Address - Phone:801-793-0620
Mailing Address - Fax:
Practice Address - Street 1:9263 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6571
Practice Address - Country:US
Practice Address - Phone:801-566-0749
Practice Address - Fax:801-566-7108
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5828209-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health