Provider Demographics
NPI:1336463298
Name:MAHAN, VICKI CLARK
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:CLARK
Last Name:MAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1848
Mailing Address - Street 2:ALL AMERICAN DRIVE
Mailing Address - City:UNIVERSITY
Mailing Address - State:MS
Mailing Address - Zip Code:38677-1848
Mailing Address - Country:US
Mailing Address - Phone:662-915-3789
Mailing Address - Fax:662-915-7831
Practice Address - Street 1:ALL AMERICAN DRIVE
Practice Address - Street 2:
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677-1848
Practice Address - Country:US
Practice Address - Phone:662-915-3789
Practice Address - Fax:662-915-7831
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0722101YP2500X
MST0357106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist