Basic Information
| Provider Information | |||||||||
| NPI: | 1194947051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGUM | ||||||||
| FirstName: | CARLTON | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | SSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ST. GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345600 | ||||||||
| FaxNumber: | 4359868700 | ||||||||
| Practice Location | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ST. GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345600 | ||||||||
| FaxNumber: | 4359868700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6496349-6004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MANGUC | 01 | UT | SBHC STAFF CODE | OTHER | 6496349-3503 | 01 | UT | STATE LICENSE | OTHER |