Provider Demographics
NPI:1023292299
Name:MANGUM, TAMARA (BS OCCUPATIONAL TH)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MANGUM
Suffix:
Gender:F
Credentials:BS OCCUPATIONAL TH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 VILLORIA
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-0938
Mailing Address - Country:US
Mailing Address - Phone:714-544-9309
Mailing Address - Fax:
Practice Address - Street 1:1663 NOYES AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606
Practice Address - Country:US
Practice Address - Phone:949-252-9946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3995225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics