Provider Demographics
NPI:1629214648
Name:MANGUM, RONALD LEE (LCAS)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:LEE
Last Name:MANGUM
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 NEW STATESIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-1165
Mailing Address - Country:US
Mailing Address - Phone:919-942-2803
Mailing Address - Fax:919-942-2126
Practice Address - Street 1:104 NEW STATESIDE DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-1165
Practice Address - Country:US
Practice Address - Phone:919-942-2803
Practice Address - Fax:919-442-1842
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC539101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)