Provider Demographics
NPI:1922859826
Name:MAHAN, COURTNEY R
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
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 1:1917 CALEB AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2520
Mailing Address - Country:US
Mailing Address - Phone:315-263-1163
Mailing Address - Fax:
Practice Address - Street 1:329 N SALINA ST STE 101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1864
Practice Address - Country:US
Practice Address - Phone:315-471-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP116757101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health