Provider Demographics
NPI:1215438239
Name:MAHAN, AMANDA L (LAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:MAHAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8116
Mailing Address - Country:US
Mailing Address - Phone:480-258-1826
Mailing Address - Fax:
Practice Address - Street 1:2060 W WHISPERING WIND DR STE 270
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-2869
Practice Address - Country:US
Practice Address - Phone:480-653-8434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-25
Last Update Date:2018-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16827101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health