Provider Demographics
NPI:1598801052
Name:MANGUM, PAUL DANIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DANIEL
Last Name:MANGUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 S MILLEDGE AVE
Mailing Address - Street 2:#3
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-6723
Mailing Address - Country:US
Mailing Address - Phone:706-546-0255
Mailing Address - Fax:706-548-6648
Practice Address - Street 1:1150 S MILLEDGE AVE
Practice Address - Street 2:#3
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-6723
Practice Address - Country:US
Practice Address - Phone:706-546-0255
Practice Address - Fax:706-548-6648
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA526103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical