Provider Demographics
NPI:1649713785
Name:MAHONEY, MARCIA
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:MAHONEY
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 1:175 CHANDLER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6524
Mailing Address - Country:US
Mailing Address - Phone:404-915-4639
Mailing Address - Fax:
Practice Address - Street 1:2899 FIVE FORKS TRICKUM RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5803
Practice Address - Country:US
Practice Address - Phone:770-633-9213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000845305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service