Provider Demographics
NPI:1346330438
Name:MAHACEK, MARK B (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:MAHACEK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19100 N FRUITPORT RD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1165
Mailing Address - Country:US
Mailing Address - Phone:616-842-2125
Mailing Address - Fax:
Practice Address - Street 1:19100 N FRUITPORT RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1165
Practice Address - Country:US
Practice Address - Phone:616-842-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM008350103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680G035200OtherBCBSM
0G03520Medicare ID - Type Unspecified