Provider Demographics
NPI:1790168680
Name:MAHAN, LAUREN CORBETT (MS)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:CORBETT
Last Name:MAHAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 MONTGOMERY LANE
Mailing Address - Street 2:
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-8052
Mailing Address - Country:US
Mailing Address - Phone:360-900-6100
Mailing Address - Fax:
Practice Address - Street 1:480 MONTGOMERY LANE
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-8052
Practice Address - Country:US
Practice Address - Phone:360-900-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13-17-13719103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst