Healthcare Provider Details

I. General information

NPI: 1558554196
Provider Name (Legal Business Name): CELENA MARTINA MAHAN LVN, CADC-CAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W CREST ST # 210
ESCONDIDO CA
92025-1739
US

IV. Provider business mailing address

125 W MISSION AVE STE 103
ESCONDIDO CA
92025-1721
US

V. Phone/Fax

Practice location:
  • Phone: 760-747-3424
  • Fax: 760-747-3435
Mailing address:
  • Phone: 760-747-3424
  • Fax: 760-747-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberM0411260826
License Number State
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number239951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: