Healthcare Provider Details

I. General information

NPI: 1104879394
Provider Name (Legal Business Name): KENNETH J. MANGES PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 SYCAMORE ST SUITE 100
CINCINNATI OH
45202-2156
US

IV. Provider business mailing address

810 SYCAMORE ST SUITE 100
CINCINNATI OH
45202-2156
US

V. Phone/Fax

Practice location:
  • Phone: 513-784-1333
  • Fax: 513-338-1920
Mailing address:
  • Phone: 513-784-1333
  • Fax: 513-338-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3656
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: