Provider Demographics
NPI:1942407358
Name:MANGELSDORF, CAROLYN ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ELIZABETH
Last Name:MANGELSDORF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23715 84TH AVE W UNIT 102
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-9511
Mailing Address - Country:US
Mailing Address - Phone:206-293-5541
Mailing Address - Fax:
Practice Address - Street 1:23715 84TH AVE W UNIT 102
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-9511
Practice Address - Country:US
Practice Address - Phone:206-293-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001960103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG217000663Medicare ID - Type UnspecifiedPSYCHOLOGIST