MEDICARE: MS. VICKI CLARK MAHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0722	MS
2	106H00000X	Marriage & Family Therapist	T0357	MS

General Provider Information

NPI Number	:	1336463298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICKI CLARK MAHAN

Provider Business Mailing Address
First Line	:	P.O. BOX 1848
Second Line	:	ALL AMERICAN DRIVE
City	:	UNIVERSITY
State	:	MS
Zip	:	38677-1848
Country	:	US
Telephone Number	:	662-915-3789
Fax Number	:	662-915-7831

Provider Business Practice Location Address
First Line	:	ALL AMERICAN DRIVE
Second Line	:
City	:	UNIVERSITY
State	:	MS
Zip	:	38677-1848
Country	:	US
Telephone Number	:	662-915-3789
Fax Number	:	662-915-7831

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2010
Last Update Date	:	03/22/2010

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Directions to “ MS. VICKI CLARK MAHAN ” Practice Location

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