Provider Demographics
NPI:1053461079
Name:MAHAN, KAREN A (LCSW MSW 4346123)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:A
Last Name:MAHAN
Suffix:
Gender:F
Credentials:LCSW MSW 4346123
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BARNARD RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-6501
Mailing Address - Country:US
Mailing Address - Phone:262-490-5465
Mailing Address - Fax:505-899-1576
Practice Address - Street 1:153 BARNARD RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-6501
Practice Address - Country:US
Practice Address - Phone:262-490-5465
Practice Address - Fax:505-899-1576
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43461231041C0700X
NMC-101941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43585500Medicaid
WI4346123OtherLCSW
WI4346123OtherLCSW