Provider Demographics
NPI:1952950222
Name:MANGUM, ERIC LELAND
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LELAND
Last Name:MANGUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SE ELLSWORTH RD APT V246
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-6234
Mailing Address - Country:US
Mailing Address - Phone:360-831-3054
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH BLVD.
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)