Provider Demographics
NPI:1316671720
Name:METCALFE-MANGRAM, INDYGO
Entity type:Individual
Prefix:
First Name:INDYGO
Middle Name:
Last Name:METCALFE-MANGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 E HENRY AVE STE B3
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-1471
Mailing Address - Country:US
Mailing Address - Phone:813-599-7813
Mailing Address - Fax:
Practice Address - Street 1:2815 E HENRY AVE STE B3
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-1471
Practice Address - Country:US
Practice Address - Phone:813-599-7813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty