Provider Demographics
NPI:1649675885
Name:MAHANA, MARY CHRISTINE (PSYD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:MAHANA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 S NATIONAL AVE PMB 319
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810
Mailing Address - Country:US
Mailing Address - Phone:417-838-3490
Mailing Address - Fax:417-763-3333
Practice Address - Street 1:901 MO 174
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1822
Practice Address - Country:US
Practice Address - Phone:417-732-1822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017007055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical