Provider Demographics
NPI:1821178997
Name:MAHONEY, JUDY RENEE (PHD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:RENEE
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5864
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92662-5864
Mailing Address - Country:US
Mailing Address - Phone:949-903-4110
Mailing Address - Fax:949-640-1709
Practice Address - Street 1:4199 CAMPUS DR
Practice Address - Street 2:SUITE 550
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-4684
Practice Address - Country:US
Practice Address - Phone:949-903-4110
Practice Address - Fax:949-640-1709
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16479103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP16479Medicare ID - Type Unspecified