Provider Demographics
NPI:1699355792
Name:MAHAN, ELIZABETH SANDRA
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SANDRA
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 1:26720 YNEZ CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4659
Mailing Address - Country:US
Mailing Address - Phone:951-813-4034
Mailing Address - Fax:
Practice Address - Street 1:26720 YNEZ CT
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4659
Practice Address - Country:US
Practice Address - Phone:951-813-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-21-164036106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician