Provider Demographics
NPI:1366712804
Name:MAHAN, RITA KATHLEEN (LCSW, RN)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:KATHLEEN
Last Name:MAHAN
Suffix:
Gender:F
Credentials:LCSW, RN
Other - Prefix:
Other - First Name:RITA
Other - Middle Name:KATHLEEN
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, RN
Mailing Address - Street 1:898 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1407
Mailing Address - Country:US
Mailing Address - Phone:317-887-1438
Mailing Address - Fax:317-885-9063
Practice Address - Street 1:898 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1407
Practice Address - Country:US
Practice Address - Phone:317-887-1438
Practice Address - Fax:317-885-9063
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000296A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty