Provider Demographics
NPI:1508927880
Name:MANGNALL-HARRIS, SUSAN Z (LCSW, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:Z
Last Name:MANGNALL-HARRIS
Suffix:
Gender:F
Credentials:LCSW, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SW FRAZER AVE
Mailing Address - Street 2:SUITE # 242
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-2163
Mailing Address - Country:US
Mailing Address - Phone:541-278-1850
Mailing Address - Fax:
Practice Address - Street 1:17 SW FRAZER AVE
Practice Address - Street 2:SUITE # 242
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-2163
Practice Address - Country:US
Practice Address - Phone:541-278-1850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL20941041C0700X
OR201150002NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2094Medicare UPIN