Provider Demographics
NPI:1992856116
Name:MAHAN, MARK J
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:MAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-1807
Mailing Address - Country:US
Mailing Address - Phone:302-472-0381
Mailing Address - Fax:302-472-0392
Practice Address - Street 1:2814 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-1807
Practice Address - Country:US
Practice Address - Phone:302-472-0381
Practice Address - Fax:302-472-0392
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000034998Medicaid