Basic Information
| Provider Information | |||||||||
| NPI: | 1972987972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANGUM | ||||||||
| FirstName: | SHENITA | ||||||||
| MiddleName: | PAULETTE | ||||||||
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| Credential: | LCSWA, LCASA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 S MADISON BLVD | ||||||||
| Address2: | SUITE C1 | ||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275735485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365998366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 355 S MADISON BLVD | ||||||||
| Address2: | SUITE C1 | ||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275735485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365998366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 07/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C010188 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | LCAS-20628 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.