Provider Demographics
NPI:1336364033
Name:MANGRUM, CHRISSONDRIA LYNN (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CHRISSONDRIA
Middle Name:LYNN
Last Name:MANGRUM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635-1112
Mailing Address - Country:US
Mailing Address - Phone:304-583-9299
Mailing Address - Fax:
Practice Address - Street 1:213 W MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-1112
Practice Address - Country:US
Practice Address - Phone:304-583-9299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0607235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist