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General NPI Number Information
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NPI Number | 1376126516
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Entity Type | Individual
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Provider Name | IAN MICHAEL MANGUS COTA/L
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Gender | Male
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Dates
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Enumeration Date | 05/05/2021
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Last Update Date | 05/05/2021
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Provider Practice Location Address
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Address Line | 2720 CHARLES TOWN RD
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City | MARTINSBURG
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State | WV
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Zip | 25405-5626
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Country | US
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Telephone | 304-263-0933
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Fax |
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Provider Business Mailing Address
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Address Line | 12614 MAHOGANY ST
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City | CUMBERLAND
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State | MD
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Zip | 21502-5181
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Country | US
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Telephone | 301-338-2745
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | A02877
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | C2351
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License Number State | WV
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