Provider Demographics
NPI:1588042089
Name:MAHAN, KAILEY ROSE (LMHC)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:ROSE
Last Name:MAHAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 OSCEOLA RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6545
Mailing Address - Country:US
Mailing Address - Phone:321-482-7429
Mailing Address - Fax:
Practice Address - Street 1:5095 S WASHINGTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7333
Practice Address - Country:US
Practice Address - Phone:407-917-6828
Practice Address - Fax:321-888-4922
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16362101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA101YM0800XOtherKINDER CONSULTING