Provider Demographics
NPI:1386115491
Name:MANGUM, DAVE (CMHC)
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:MANGUM
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E 9800 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3546
Mailing Address - Country:US
Mailing Address - Phone:801-793-0600
Mailing Address - Fax:
Practice Address - Street 1:7069 S HIGHLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3731
Practice Address - Country:US
Practice Address - Phone:801-793-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8460542-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health