MEDICARE: EMILY MANGOLD DPT

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	225100000X	Physical Therapist	070025939	IL

General Provider Information

NPI Number	:	1154164994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY MANGOLD DPT

Provider Business Mailing Address
First Line	:	387 OLD GERMANTOWN RD
Second Line	:
City	:	GERMANTOWN HILLS
State	:	IL
Zip	:	61548-8679
Country	:	US
Telephone Number	:	309-383-2772
Fax Number	:

Provider Business Practice Location Address
First Line	:	387 OLD GERMANTOWN RD
Second Line	:
City	:	GERMANTOWN HILLS
State	:	IL
Zip	:	61548-8679
Country	:	US
Telephone Number	:	309-383-2772
Fax Number	:

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

Provider Enumeration Date	:	06/18/2024
Last Update Date	:	06/18/2024

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