Provider Demographics
NPI:1396500062
Name:MAHAN, WESLEY
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:MAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8032 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48450-9719
Mailing Address - Country:US
Mailing Address - Phone:810-201-4987
Mailing Address - Fax:
Practice Address - Street 1:8032 LAKESHORE ROAD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:UNITED STATES
Practice Address - Zip Code:48450
Practice Address - Country:UM
Practice Address - Phone:810-201-4987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician