Provider Demographics
NPI:1508202219
Name:MANGUM-CHILDERS, LAURA ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:MANGUM-CHILDERS
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 1:187 HIGH ST NE
Mailing Address - Street 2:SUITE #216
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3689
Mailing Address - Country:US
Mailing Address - Phone:971-600-4358
Mailing Address - Fax:
Practice Address - Street 1:187 HIGH ST NE
Practice Address - Street 2:SUITE #216
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3689
Practice Address - Country:US
Practice Address - Phone:971-600-4358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99230451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical