Provider Demographics
NPI:1003191628
Name:MAHONEY, SUSAN MARIE
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:28273 ROCKLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHAUMONT
Mailing Address - State:NY
Mailing Address - Zip Code:13622-0533
Mailing Address - Country:US
Mailing Address - Phone:781-581-1852
Mailing Address - Fax:
Practice Address - Street 1:1635 OHIO ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3032
Practice Address - Country:US
Practice Address - Phone:315-786-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033802-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics