MEDICARE: DR. MICHAEL WILLIAM MANGIS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist		IL

General Provider Information

NPI Number	:	1063405249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL WILLIAM MANGIS PH.D.

Provider Business Mailing Address
First Line	:	106 W PIERCE ST
Second Line	:
City	:	ELBURN
State	:	IL
Zip	:	60119-8201
Country	:	US
Telephone Number	:	630-365-0899
Fax Number	:	630-365-9150

Provider Business Practice Location Address
First Line	:	106 W PIERCE ST
Second Line	:
City	:	ELBURN
State	:	IL
Zip	:	60119-8201
Country	:	US
Telephone Number	:	630-365-0899
Fax Number	:	630-365-9150

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	01/31/2008

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