Individual
RYAN MANGUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
600 N ROBBINS RD, BOISE, ID 83702-4565
(208) 381-9037
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
PSY-203778
ID
103G00000X
Clinical Neuropsychologist
PY61070460
WA
103TC0700X
Clinical Psychologist
6301018219
MI
103TC0700X
Clinical Psychologist
PY61070460
WA
Other
Enumeration date
03/18/2020
Last updated
03/29/2023
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