Provider Demographics
NPI:1780878652
Name:MANGARELLI-KALLENBERG, LAURA (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MANGARELLI-KALLENBERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 SPANISH MOSS DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TX
Mailing Address - Zip Code:76227-7781
Mailing Address - Country:US
Mailing Address - Phone:972-347-1586
Mailing Address - Fax:
Practice Address - Street 1:2535 W OAK ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2331
Practice Address - Country:US
Practice Address - Phone:940-382-2649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1137727225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB118159Medicare PIN