Provider Demographics
NPI:1376297895
Name:MAHAN, MICAIAH ELLIE
Entity Type:Individual
Prefix:
First Name:MICAIAH
Middle Name:ELLIE
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 1:1224 W ROSEMONT AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1519
Mailing Address - Country:US
Mailing Address - Phone:224-318-7120
Mailing Address - Fax:
Practice Address - Street 1:5150 GOLF RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1283
Practice Address - Country:US
Practice Address - Phone:224-318-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0239171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical