=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790727451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE M MANGUM PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8390 LBJ FREEWAY SUITE 1000
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-1288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-361-2100
-----------------------------------------------------
Fax | 214-361-2145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 537
-----------------------------------------------------
City | SULPHUR SPRINGS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75483-0537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-361-2100
-----------------------------------------------------
Fax | 214-361-2145
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 33427
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------