Provider Demographics
NPI:1265017198
Name:MAHAN, LUCRETIA (ASW)
Entity Type:Individual
Prefix:
First Name:LUCRETIA
Middle Name:
Last Name:MAHAN
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:LUCRETIA
Other - Middle Name:
Other - Last Name:DENDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-255-7520
Mailing Address - Fax:619-713-0480
Practice Address - Street 1:3845 SPRING DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-1030
Practice Address - Country:US
Practice Address - Phone:619-515-2338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9633831041C0700X
CA96383101YM0800X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator