Provider Demographics
NPI:1053461079
Name:MAHAN, KAREN A (LCSW MSW 4346123)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:A
Last Name:MAHAN
Suffix:
Gender:F
Credentials:LCSW MSW 4346123
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W304S5186 STATE ROAD 83
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8725
Mailing Address - Country:US
Mailing Address - Phone:262-490-5465
Mailing Address - Fax:262-720-7743
Practice Address - Street 1:925 ELM GROVE RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2572
Practice Address - Country:US
Practice Address - Phone:262-490-5465
Practice Address - Fax:262-720-7743
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43461231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4346123OtherLCSW
WI43585500Medicaid
WI4346123OtherLCSW