Provider Demographics
NPI:1194316885
Name:MANGAL, LAHORE KHAN (RBT)
Entity type:Individual
Prefix:MR
First Name:LAHORE
Middle Name:KHAN
Last Name:MANGAL
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12265 AZTEC PL
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1817
Mailing Address - Country:US
Mailing Address - Phone:540-764-8227
Mailing Address - Fax:
Practice Address - Street 1:1964 GALLOWS RD STE 302
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3814
Practice Address - Country:US
Practice Address - Phone:703-508-6162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-20-136359106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician