Healthcare Provider Details

I. General information

NPI: 1033623376
Provider Name (Legal Business Name): LORI BETH MANGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 BUTTERMILK PIKE STE 200
CRESCENT SPRINGS KY
41017-1696
US

IV. Provider business mailing address

103 FOX MEADOW RUN
JUPITER FL
33458-5504
US

V. Phone/Fax

Practice location:
  • Phone: 859-869-2023
  • Fax: 561-401-9196
Mailing address:
  • Phone: 859-250-6898
  • Fax: 561-401-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number292540
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17168
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number252940
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: