Provider Demographics
NPI:1881031532
Name:SPEARS, MAHOGANY
Entity Type:Individual
Prefix:
First Name:MAHOGANY
Middle Name:
Last Name:SPEARS
Suffix:
Gender:F
Credentials:
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 1812
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-0812
Mailing Address - Country:US
Mailing Address - Phone:925-222-5685
Mailing Address - Fax:
Practice Address - Street 1:1423 BROADWAY # 572
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2054
Practice Address - Country:US
Practice Address - Phone:925-222-5685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116215106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist