Provider Demographics
NPI:1740831981
Name:MAHOGANY PLACE PLLC
Entity type:Organization
Organization Name:MAHOGANY PLACE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER/MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:910-808-1881
Mailing Address - Street 1:125 BELLA HOWINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-5666
Mailing Address - Country:US
Mailing Address - Phone:910-808-1881
Mailing Address - Fax:
Practice Address - Street 1:125 BELLA HOWINGTON DR
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-5666
Practice Address - Country:US
Practice Address - Phone:910-808-1881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty