Provider Demographics
NPI:1417263609
Name:MAHONEY, MARTIN JAMES (AUD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:JAMES
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 CHESHIRE PKWY N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4103
Mailing Address - Country:US
Mailing Address - Phone:888-510-0766
Mailing Address - Fax:763-268-4017
Practice Address - Street 1:310 N CLIPPERT ST
Practice Address - Street 2:STE 4
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4694
Practice Address - Country:US
Practice Address - Phone:517-322-1691
Practice Address - Fax:517-324-0210
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000561231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640E801070OtherBCBS