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General NPI Number Information
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NPI Number | 1902612468
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Entity Type | Individual
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Provider Name | TIMOTHY MANGUM JR.
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Gender | Male
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Dates
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Enumeration Date | 12/09/2024
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Last Update Date | 12/09/2024
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Provider Practice Location Address
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Address Line | 215 WESTLAKE DR
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City | SANDERSVILLE
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State | GA
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Zip | 31082-9427
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Country | US
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Telephone | 919-810-3283
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Fax |
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Provider Business Mailing Address
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Address Line | 215 WESTLAKE DR
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City | SANDERSVILLE
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State | GA
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Zip | 31082-9427
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Country | US
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Telephone |
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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 | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 1297566
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 324407
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 233771
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License Number State | NV
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Taxonomy #4
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 1962506
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License Number State | GA
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Taxonomy #5
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 72050
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License Number State | TX
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