Provider Demographics
NPI:1144793936
Name:MAHONEY, PAUL ANDREW II (AT,C LAT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANDREW
Last Name:MAHONEY
Suffix:II
Gender:M
Credentials:AT,C LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36668 CATALPA LN
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5578
Mailing Address - Country:US
Mailing Address - Phone:586-612-5120
Mailing Address - Fax:
Practice Address - Street 1:6319 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:IRA
Practice Address - State:MI
Practice Address - Zip Code:48023-1003
Practice Address - Country:US
Practice Address - Phone:586-648-2528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010006112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2601000611OtherSTATE OF MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
049302490OtherBOARD OF CERTIFICATION INC. (BOC)