Provider Demographics
NPI:1750716205
Name:MANGOLD, LISA ANN (LPC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:MANGOLD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 GRAND OAK CIR
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:SC
Mailing Address - Zip Code:29670-1648
Mailing Address - Country:US
Mailing Address - Phone:832-724-3524
Mailing Address - Fax:
Practice Address - Street 1:125 MUDDY TOES DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29626-5349
Practice Address - Country:US
Practice Address - Phone:864-353-3384
Practice Address - Fax:864-222-9715
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67967101YP2500X
SC5605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional