Basic Information
| Provider Information | |||||||||
| NPI: | 1437203973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHONEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | BA BVNUS CACII ARMSI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68438 KLINGER LAKE RD | ||||||||
| Address2: | |||||||||
| City: | STURGIS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490919290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696590999 | ||||||||
| FaxNumber: | 2696598472 | ||||||||
| Practice Location | |||||||||
| Address1: | 70050 M 66 | ||||||||
| Address2: | |||||||||
| City: | STURGIS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696511212 | ||||||||
| FaxNumber: | 2696598472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 200482 | MI | Y | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | A10429 | MI | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.