Provider Demographics
NPI:1821669912
Name:MANGAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MANGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702B S CARTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-6642
Mailing Address - Country:US
Mailing Address - Phone:801-735-1229
Mailing Address - Fax:
Practice Address - Street 1:1165 E 300 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3539
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:801-373-0639
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT284431-35061041C0700X
UT284431-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical