Provider Demographics
NPI:1639155104
Name:MAHAN, DARRELL F (LCSW)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:F
Last Name:MAHAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-4221
Mailing Address - Country:US
Mailing Address - Phone:417-255-8464
Mailing Address - Fax:417-255-9741
Practice Address - Street 1:1115 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-4221
Practice Address - Country:US
Practice Address - Phone:417-255-8464
Practice Address - Fax:417-255-9741
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030038821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4990055228Medicaid
MOPENDINGMedicare ID - Type Unspecified
MO4990055228Medicaid