Healthcare Provider Details

I. General information

NPI: 1669127700
Provider Name (Legal Business Name): CHRISTINA NICOLE MANGOLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E DIVISION ST
SPARTA MI
49345-1328
US

IV. Provider business mailing address

1355 13 MILE RD NE
SPARTA MI
49345-8363
US

V. Phone/Fax

Practice location:
  • Phone: 231-729-1384
  • Fax:
Mailing address:
  • Phone: 231-729-1384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801120412
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: