Provider Demographics
NPI:1861607574
Name:MANGUM BEHAVIORAL ASSOCIATES, PA
Entity type:Organization
Organization Name:MANGUM BEHAVIORAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRISON
Authorized Official - Middle Name:MANGUM
Authorized Official - Last Name:KISNER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISW-CP
Authorized Official - Phone:864-360-4341
Mailing Address - Street 1:7C CLEVELAND CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2414
Mailing Address - Country:US
Mailing Address - Phone:864-360-4341
Mailing Address - Fax:864-239-6968
Practice Address - Street 1:7C CLEVELAND CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2414
Practice Address - Country:US
Practice Address - Phone:864-360-4341
Practice Address - Fax:864-239-6968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0064531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty