Provider Demographics
NPI:1578753232
Name:MANGOLD, MARY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:MANGOLD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 E MISSOURI AVE
Mailing Address - Street 2:STE A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2615
Mailing Address - Country:US
Mailing Address - Phone:602-393-0520
Mailing Address - Fax:602-393-0523
Practice Address - Street 1:1020 E MISSOURI AVE
Practice Address - Street 2:STE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2615
Practice Address - Country:US
Practice Address - Phone:602-393-0520
Practice Address - Fax:602-393-0523
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7754225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z116879Medicare PIN