Provider Demographics
NPI:1639449648
Name:MANGREM, IDA (PTA)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:MANGREM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N GRANDVIEW AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1600
Mailing Address - Country:US
Mailing Address - Phone:432-550-4700
Mailing Address - Fax:432-550-4715
Practice Address - Street 1:2525 N GRANDVIEW AVE
Practice Address - Street 2:STE 400
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-1600
Practice Address - Country:US
Practice Address - Phone:432-550-4700
Practice Address - Fax:432-550-4715
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2083203225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant