Provider Demographics
NPI:1245982289
Name:MANGAN, DESTINY MILLER (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DESTINY
Middle Name:MILLER
Last Name:MANGAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 RIDGECREST CIR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-4110
Mailing Address - Country:US
Mailing Address - Phone:678-357-5849
Mailing Address - Fax:
Practice Address - Street 1:165 RIDGECREST CIR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-4110
Practice Address - Country:US
Practice Address - Phone:678-357-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003509235Z00000X
GASLP012443235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist