Provider Demographics
NPI:1083003859
Name:MAHONEY, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MAHONEY
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 1:1328 BLUE OAKS BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-7031
Mailing Address - Country:US
Mailing Address - Phone:916-676-0488
Mailing Address - Fax:916-771-4370
Practice Address - Street 1:1325 HOWE AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3364
Practice Address - Country:US
Practice Address - Phone:916-676-0488
Practice Address - Fax:916-771-4370
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14910103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst