Healthcare Provider Details

I. General information

NPI: 1508927880
Provider Name (Legal Business Name): SUSAN Z MANGNALL-HARRIS L.C.S.W., PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SW FRAZER AVE SUITE # 242
PENDLETON OR
97801-2163
US

IV. Provider business mailing address

17 SW FRAZER AVE SUITE # 242
PENDLETON OR
97801-2163
US

V. Phone/Fax

Practice location:
  • Phone: 541-278-1850
  • Fax:
Mailing address:
  • Phone: 541-278-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL2094
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201150002NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: