Provider Demographics
NPI:1942593694
Name:MANGUM, SAMANTHA K
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:K
Last Name:MANGUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-3628
Mailing Address - Country:US
Mailing Address - Phone:210-875-7533
Mailing Address - Fax:
Practice Address - Street 1:1333 IRIS AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-2226
Practice Address - Country:US
Practice Address - Phone:303-444-9126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health