Provider Demographics
NPI:1518372077
Name:MANGIN, CLARA JULIANNE
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:JULIANNE
Last Name:MANGIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12663 ASHGLEN DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1350
Mailing Address - Country:US
Mailing Address - Phone:904-517-9341
Mailing Address - Fax:
Practice Address - Street 1:12663 ASHGLEN DR S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1350
Practice Address - Country:US
Practice Address - Phone:904-517-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL20079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst