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General NPI Number Information
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NPI Number | 1477201721
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Entity Type | Organization
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Legal Business Name | MANGOLD ENTERPRISE
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Dates
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Enumeration Date | 03/16/2022
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Last Update Date | 03/16/2022
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Provider Practice Location Address
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Address Line | 2417 HOBBS RD STE 105
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City | AMARILLO
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State | TX
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Zip | 79109-1533
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Country | US
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Telephone | 806-471-0334
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 271
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City | CANYON
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State | TX
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Zip | 79015-0271
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Country | US
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Telephone | 806-471-0334
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Fax | 806-318-3046
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Authorized Official
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Title or Position | OWNER
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Name | KELLI MANGOLD
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Credential | LCSW
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Telephone | 806-471-0334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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