Provider Demographics
NPI:1104270081
Name:MAHIEU, RICHARD (MED, ATC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:MAHIEU
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-1756
Mailing Address - Country:US
Mailing Address - Phone:770-207-6624
Mailing Address - Fax:
Practice Address - Street 1:1219 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-1756
Practice Address - Country:US
Practice Address - Phone:770-207-6624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0023542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer