Provider Demographics
NPI:1841672052
Name:MAHONEY, MICHAEL JR (MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MAHONEY
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45410 MALLARD ST
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-2527
Mailing Address - Country:US
Mailing Address - Phone:703-955-6983
Mailing Address - Fax:
Practice Address - Street 1:13890 BRADDOCK RD
Practice Address - Street 2:STE. 207
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2435
Practice Address - Country:US
Practice Address - Phone:540-720-2261
Practice Address - Fax:540-720-5660
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007902235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist