Provider Demographics
NPI:1790727451
Name:MANGUM, NICOLE J (PH D)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:MANGUM
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10355 TEXAS HIGHWAY 154 S
Mailing Address - Street 2:
Mailing Address - City:YANTIS
Mailing Address - State:TX
Mailing Address - Zip Code:75497-7475
Mailing Address - Country:US
Mailing Address - Phone:214-692-6686
Mailing Address - Fax:469-587-8439
Practice Address - Street 1:7557 RAMBLER RD
Practice Address - Street 2:SUITE 740
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4142
Practice Address - Country:US
Practice Address - Phone:214-361-2100
Practice Address - Fax:214-361-2145
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33427103G00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist