Provider Demographics
NPI:1659799500
Name:MAHONEY, MICHAEL WILLIAM (LADC, NCAC1)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:LADC, NCAC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 ASSISI DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-1637
Mailing Address - Country:US
Mailing Address - Phone:507-218-3450
Mailing Address - Fax:855-856-5734
Practice Address - Street 1:1530 ASSISI DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1637
Practice Address - Country:US
Practice Address - Phone:507-218-3450
Practice Address - Fax:855-856-5734
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301050101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)