Provider Demographics
NPI:1255715330
Name:MAHONEY, COLIN (SE)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:SE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 YELLOWSTONE AVE
Mailing Address - Street 2:STE C5
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4374
Mailing Address - Country:US
Mailing Address - Phone:208-233-0150
Mailing Address - Fax:208-233-0159
Practice Address - Street 1:1246 YELLOWSTONE AVE
Practice Address - Street 2:STE C5
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4374
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:208-233-0159
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist