Provider Demographics
NPI:1316930357
Name:MAHAN, SUELLYN M (PHD)
Entity type:Individual
Prefix:MS
First Name:SUELLYN
Middle Name:M
Last Name:MAHAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E PUGH DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3942
Mailing Address - Country:US
Mailing Address - Phone:812-236-9569
Mailing Address - Fax:812-235-2929
Practice Address - Street 1:1400 E PUGH DR
Practice Address - Street 2:SUITE 3
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3942
Practice Address - Country:US
Practice Address - Phone:812-236-9569
Practice Address - Fax:812-235-2929
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041149103TC0700X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200154190Medicaid
IN200154190Medicaid