Provider Demographics
NPI:1255842324
Name:MAHAN, MICAH (MHPP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MAHAN
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 679
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110-0679
Mailing Address - Country:US
Mailing Address - Phone:501-354-4589
Mailing Address - Fax:501-354-5410
Practice Address - Street 1:100 S. CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-0679
Practice Address - Country:US
Practice Address - Phone:501-354-4589
Practice Address - Fax:501-477-2488
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty