Provider Demographics
NPI:1053071092
Name:MAHONEY, MICHAEL (BCBA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WEDGEWOOD DR APT 2
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-3673
Mailing Address - Country:US
Mailing Address - Phone:203-510-7807
Mailing Address - Fax:
Practice Address - Street 1:220 MAIN ST S
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2275
Practice Address - Country:US
Practice Address - Phone:203-920-0520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst