Basic Information
| Provider Information | |||||||||
| NPI: | 1841549078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHAN | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379171209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019937822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4726 AIRPORT HWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377775402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659707747 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2012 | ||||||||
| LastUpdateDate: | 03/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LSW0000012102 | TN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.