Provider Demographics
NPI:1417420068
Name:MAHAN, LAURA LEE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
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 1:207 RUBENS DR APT D
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-4212
Mailing Address - Country:US
Mailing Address - Phone:802-595-3896
Mailing Address - Fax:
Practice Address - Street 1:207 RUBENS DR APT D
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-4212
Practice Address - Country:US
Practice Address - Phone:802-595-3896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL222Q00000XMedicaid