Provider Demographics
NPI:1215384128
Name:MAHONEY, KEVIN CHARLES (SLP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHARLES
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 A ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2124
Mailing Address - Country:US
Mailing Address - Phone:646-637-7872
Mailing Address - Fax:
Practice Address - Street 1:861 HAROLD PL
Practice Address - Street 2:#205
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4553
Practice Address - Country:US
Practice Address - Phone:619-578-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23678235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist