MEDICARE: HEATHER MELISSA MANGRUM MS CCC-SLP

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	235Z00000X	Speech-Language Pathologist		MS

General Provider Information

NPI Number	:	1780057638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER MELISSA MANGRUM MS CCC-SLP

Provider Business Mailing Address
First Line	:	139 W LAKE LEE RD
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-9573
Country	:	US
Telephone Number	:	662-822-1322
Fax Number	:

Provider Business Practice Location Address
First Line	:	139 W LAKE LEE RD
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-9573
Country	:	US
Telephone Number	:	662-822-1322
Fax Number	:

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

Provider Enumeration Date	:	11/01/2015
Last Update Date	:	11/01/2015

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Directions to “ HEATHER MELISSA MANGRUM MS CCC-SLP” Practice Location

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