Healthcare Provider Details

I. General information

NPI: 1154834752
Provider Name (Legal Business Name): DENNIS MAHONEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12490 ALTA MESA RD
HERALD CA
95638-8409
US

IV. Provider business mailing address

500 22ND ST
SACRAMENTO CA
95816-3503
US

V. Phone/Fax

Practice location:
  • Phone: 209-748-5073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI32630421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: