Healthcare Provider Details

I. General information

NPI: 1609258342
Provider Name (Legal Business Name): MRS. LAURA KATHERINE MANGRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

IV. Provider business mailing address

316 ESTELLA CT
FLORENCE AL
35630-2874
US

V. Phone/Fax

Practice location:
  • Phone: 256-381-4330
  • Fax:
Mailing address:
  • Phone: 931-607-3386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: