Provider Demographics
NPI:1154518876
Name:MANGUM, KIMBERLY GRAY (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GRAY
Last Name:MANGUM
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 STANNARY PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-7814
Mailing Address - Country:US
Mailing Address - Phone:352-682-8996
Mailing Address - Fax:
Practice Address - Street 1:7209 CREEDMOOR RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1625
Practice Address - Country:US
Practice Address - Phone:919-844-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6619225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics