Provider Demographics
NPI:1205584067
Name:MANGHAM, MIKEISHA (OTR/L)
Entity type:Individual
Prefix:
First Name:MIKEISHA
Middle Name:
Last Name:MANGHAM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SW 75TH ST APT C01
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1602
Mailing Address - Country:US
Mailing Address - Phone:352-363-4059
Mailing Address - Fax:
Practice Address - Street 1:75 SW 75TH ST APT C01
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1602
Practice Address - Country:US
Practice Address - Phone:352-363-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-04-25
Deactivation Date:2022-03-11
Deactivation Code:
Reactivation Date:2022-03-29
Provider Licenses
StateLicense IDTaxonomies
FL22787225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist