Provider Demographics
NPI:1821601733
Name:MANGAN, ELIZABETH TENNEY (MS)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:TENNEY
Last Name:MANGAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05773-9800
Mailing Address - Country:US
Mailing Address - Phone:802-446-3577
Mailing Address - Fax:802-446-3801
Practice Address - Street 1:167 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:VT
Practice Address - Zip Code:05773-9800
Practice Address - Country:US
Practice Address - Phone:802-446-3577
Practice Address - Fax:802-446-3801
Is Sole Proprietor?:No
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health