Provider Demographics
NPI:1689165599
Name:MANGUM, SOMMER (MS, BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:SOMMER
Middle Name:
Last Name:MANGUM
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666-2082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 MAIN ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21666-2082
Practice Address - Country:US
Practice Address - Phone:443-226-8381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-17-45297106S00000X
MDLBA1504103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician