Provider Demographics
NPI:1548285216
Name:MANGUM, KRISTIN R (PH D)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:R
Last Name:MANGUM
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CADENCIA ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92694-1296
Mailing Address - Country:US
Mailing Address - Phone:469-396-9146
Mailing Address - Fax:
Practice Address - Street 1:17 CADENCIA ST
Practice Address - Street 2:
Practice Address - City:RANCHO MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92694-1296
Practice Address - Country:US
Practice Address - Phone:469-396-9146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28136103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN062Medicare ID - Type Unspecified