Provider Demographics
NPI:1861939514
Name:MCMAHAN, FRED
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:MCMAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 MEMORIAL CIR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5001
Mailing Address - Country:US
Mailing Address - Phone:386-310-8766
Mailing Address - Fax:
Practice Address - Street 1:565 MEMORIAL CIR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5001
Practice Address - Country:US
Practice Address - Phone:386-310-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker