Provider Demographics
NPI:1740395193
Name:MANGUS-HAYDEN, MALLORI NICOLE (LPC)
Entity Type:Individual
Prefix:MS
First Name:MALLORI
Middle Name:NICOLE
Last Name:MANGUS-HAYDEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2458 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4236
Mailing Address - Country:US
Mailing Address - Phone:432-582-2444
Mailing Address - Fax:432-582-2449
Practice Address - Street 1:2458 E 11TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4236
Practice Address - Country:US
Practice Address - Phone:432-582-2444
Practice Address - Fax:432-582-2449
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179089101Medicaid