Provider Demographics
NPI:1417121476
Name:MAHAN, RICHARD BRIAN (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRIAN
Last Name:MAHAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N SANTA CRUZ AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5919
Mailing Address - Country:US
Mailing Address - Phone:408-409-0039
Mailing Address - Fax:408-620-1340
Practice Address - Street 1:110 N SANTA CRUZ AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5919
Practice Address - Country:US
Practice Address - Phone:408-409-0039
Practice Address - Fax:408-620-1340
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-21
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23768103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical