Healthcare Provider Details

I. General information

NPI: 1770268120
Provider Name (Legal Business Name): JAMES VICTOR MANGAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8149 GREEN VALLEY DR
GRAND BLANC MI
48439-8171
US

IV. Provider business mailing address

8149 GREEN VALLEY DR
GRAND BLANC MI
48439-8171
US

V. Phone/Fax

Practice location:
  • Phone: 616-987-0883
  • Fax:
Mailing address:
  • Phone: 616-987-0883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451023078
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: