Provider Demographics
NPI:1437203973
Name:MAHONEY, ROBERT J (BA BVNUS CACII ARMSI)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:BA BVNUS CACII ARMSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68438 KLINGER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-9290
Mailing Address - Country:US
Mailing Address - Phone:269-659-0999
Mailing Address - Fax:269-659-8472
Practice Address - Street 1:70050 M 66
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091
Practice Address - Country:US
Practice Address - Phone:269-651-1212
Practice Address - Fax:269-659-8472
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI200482101Y00000X
MIA10429101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor