Provider Demographics
NPI:1972987972
Name:MANGUM, SHENITA PAULETTE (LCSWA, LCASA)
Entity type:Individual
Prefix:
First Name:SHENITA
Middle Name:PAULETTE
Last Name:MANGUM
Suffix:
Gender:F
Credentials:LCSWA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 S MADISON BLVD
Mailing Address - Street 2:SUITE C1
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-5485
Mailing Address - Country:US
Mailing Address - Phone:336-599-8366
Mailing Address - Fax:
Practice Address - Street 1:355 S MADISON BLVD
Practice Address - Street 2:SUITE C1
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-5485
Practice Address - Country:US
Practice Address - Phone:336-599-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0101881041C0700X
NCLCAS-20628101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)