Provider Demographics
NPI:1417201989
Name:MANGANDI, KRYSTAL PENMAN (LCSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:PENMAN
Last Name:MANGANDI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8883
Mailing Address - Country:US
Mailing Address - Phone:704-537-1202
Mailing Address - Fax:704-537-1209
Practice Address - Street 1:5855 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 111
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8883
Practice Address - Country:US
Practice Address - Phone:704-537-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0080711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical