Provider Demographics
NPI:1609115369
Name:MANGRUM, RECAIRDO DEMETRIUS (PHD)
Entity Type:Individual
Prefix:MR
First Name:RECAIRDO
Middle Name:DEMETRIUS
Last Name:MANGRUM
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 1:2235 COVENTRY RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-3032
Mailing Address - Country:US
Mailing Address - Phone:570-713-9112
Mailing Address - Fax:
Practice Address - Street 1:7540 ALLENTOWN BLVD STE 5
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-4238
Practice Address - Country:US
Practice Address - Phone:717-418-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-12387103K00000X
PABH000158103K00000X
VA0133000226103K00000X
MDLBA972103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst