Healthcare Provider Details

I. General information

NPI: 1053461079
Provider Name (Legal Business Name): KAREN A MAHAN LCSW MSW 4346123
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 BARNARD RD
CORRALES NM
87048-6501
US

IV. Provider business mailing address

153 BARNARD RD
CORRALES NM
87048-6501
US

V. Phone/Fax

Practice location:
  • Phone: 262-490-5465
  • Fax: 505-899-1576
Mailing address:
  • Phone: 262-490-5465
  • Fax: 505-899-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4346123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10194
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: