Provider Demographics
NPI:1457038911
Name:MAHAN, RENEE NICOLE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
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 1:100 N HOWARD ST STE W
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:623-254-9422
Mailing Address - Fax:
Practice Address - Street 1:100 N HOWARD ST STE W
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0508
Practice Address - Country:US
Practice Address - Phone:623-254-9422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2024-08-30
Deactivation Date:2024-08-27
Deactivation Code:
Reactivation Date:2024-08-30
Provider Licenses
StateLicense IDTaxonomies
WASC615410381041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty