Provider Demographics
NPI:1942500608
Name:MAHAN, MICHAEL R (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MAHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 FALLS CREEK DR.
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-9415
Mailing Address - Country:US
Mailing Address - Phone:937-890-9235
Mailing Address - Fax:937-890-9239
Practice Address - Street 1:830 FALLS CREEK DR.
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-9415
Practice Address - Country:US
Practice Address - Phone:937-890-9235
Practice Address - Fax:937-890-9239
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT001700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist