Healthcare Provider Details

I. General information

NPI: 1720801855
Provider Name (Legal Business Name): HEATHER MAHONEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 S 2ND ST
SAN JOSE CA
95112-5974
US

IV. Provider business mailing address

1144 S 2ND ST
SAN JOSE CA
95112-5974
US

V. Phone/Fax

Practice location:
  • Phone: 510-988-7142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: