MEDICARE: MAHAN COUNSELING, LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1285291633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAHAN COUNSELING, LLC

Provider Business Mailing Address
First Line	:	4440 OSCEOLA RD
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-6545
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5095 S WASHINGTON AVE STE 102
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-7333
Country	:	US
Telephone Number	:	407-917-6828
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR, OWNER
Name	:	MRS. KAILEY ROSE MAHAN
Credential	:	LMHC
Telephone Number	:	407-917-6828

Provider Enumeration Date	:	05/21/2019
Last Update Date	:	05/21/2019

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