Provider Demographics
NPI:1619476090
Name:MANGRUM BROWN, BRIDGET DENISE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:DENISE
Last Name:MANGRUM BROWN
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12318 BOYDTON PLANK RD
Mailing Address - Street 2:
Mailing Address - City:DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23841-2454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12318 BOYDTON PLANK RD
Practice Address - Street 2:
Practice Address - City:DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23841-2454
Practice Address - Country:US
Practice Address - Phone:540-369-2389
Practice Address - Fax:877-734-1914
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-19-36049103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619476090Medicaid