Provider Demographics
NPI:1720395031
Name:MANGUS, KATHLEEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MANGUS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S 400 E
Mailing Address - Street 2:CARE OF THE CHILDREN'S CENTER
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2908
Mailing Address - Country:US
Mailing Address - Phone:801-318-7362
Mailing Address - Fax:801-582-5540
Practice Address - Street 1:350 S 400 E
Practice Address - Street 2:CARE OF THE CHILDREN'S CENTER
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2908
Practice Address - Country:US
Practice Address - Phone:801-318-7362
Practice Address - Fax:801-582-5540
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT77195384201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist