Provider Demographics
NPI:1861958191
Name:MANGAN, MELISSA INEZ (COTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:INEZ
Last Name:MANGAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503
Mailing Address - Street 2:
Mailing Address - City:CHIRENO
Mailing Address - State:TX
Mailing Address - Zip Code:75937-0503
Mailing Address - Country:US
Mailing Address - Phone:936-645-3323
Mailing Address - Fax:
Practice Address - Street 1:220 E ASH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:TX
Practice Address - Zip Code:75949-8648
Practice Address - Country:US
Practice Address - Phone:936-876-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214749224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant