Provider Demographics
NPI:1427692284
Name:MAHAN, CONNOR (MOT, OTR)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:MAHAN
Suffix:
Gender:M
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PENNSYLVANIA AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-7401
Mailing Address - Country:US
Mailing Address - Phone:757-771-9360
Mailing Address - Fax:
Practice Address - Street 1:5700 WILLIAMSBURG LANDING DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3779
Practice Address - Country:US
Practice Address - Phone:800-554-5517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MA13597225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist