Provider Demographics
NPI:1588999064
Name:MANGUS, MIKE L
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:L
Last Name:MANGUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-5865
Mailing Address - Country:US
Mailing Address - Phone:405-222-5555
Mailing Address - Fax:405-222-2028
Practice Address - Street 1:428 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-5865
Practice Address - Country:US
Practice Address - Phone:405-222-5555
Practice Address - Fax:405-222-2028
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK679235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist