Provider Demographics
NPI:1114437712
Name:MANGAN, STEPHANIE (OT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MANGAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 MOUNT VERNON RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2904
Mailing Address - Country:US
Mailing Address - Phone:540-521-7918
Mailing Address - Fax:
Practice Address - Street 1:18596 LEE HWY STE B
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-8004
Practice Address - Country:US
Practice Address - Phone:276-525-6043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004489225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist