MEDICARE: MS. ELIZABETH MANGUM LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	059443	NY
2	1041C0700X	Clinical Social Worker	076115	NY

General Provider Information

NPI Number	:	1346386869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH MANGUM LCSW

Provider Business Mailing Address
First Line	:	196 ST. MARK'S AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11238
Country	:	US
Telephone Number	:	917-414-5595
Fax Number	:

Provider Business Practice Location Address
First Line	:	371 8TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-3604
Country	:	US
Telephone Number	:	512-534-8425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	02/08/2019

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