MEDICARE: SAMANTHA JOLIN MANGAR LPC

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	101YP2500X	Professional Counselor	LPC.0019871	CO

General Provider Information

NPI Number	:	1447030085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA JOLIN MANGAR LPC

Provider Business Mailing Address
First Line	:	4342 PARKWOOD TRL
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-7707
Country	:	US
Telephone Number	:	719-209-8690
Fax Number	:

Provider Business Practice Location Address
First Line	:	4342 PARKWOOD TRL
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-7707
Country	:	US
Telephone Number	:	719-209-8690
Fax Number	:

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

Provider Enumeration Date	:	10/02/2023
Last Update Date	:	10/02/2023

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