=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881115699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN LESLIE MAHAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2017
-----------------------------------------------------
Last Update Date | 01/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1508 F ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95814-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-896-9716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 308 SAVOY AVE
-----------------------------------------------------
City | RIO LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95673-1320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 191-689-6971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------