=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508202219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ELIZABETH MANGUM-CHILDERS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2013
-----------------------------------------------------
Last Update Date | 10/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 HIGH ST NE SUITE #216
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-3689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-600-4358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 187 HIGH ST NE SUITE #216
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-3689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-600-4358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9923045
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------