Provider Demographics
NPI:1073987046
Name:MAHONEY, TARA (CADC II)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SW FRAZER AVE # 219
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-2800
Mailing Address - Country:US
Mailing Address - Phone:541-276-1022
Mailing Address - Fax:541-215-1021
Practice Address - Street 1:920 SW FRAZER AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-2800
Practice Address - Country:US
Practice Address - Phone:541-276-1022
Practice Address - Fax:541-215-1021
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00-11-47101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)