Healthcare Provider Details

I. General information

NPI: 1982171922
Provider Name (Legal Business Name): MICHAEL MAHONEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3828 W TAYLOR ST
CHICAGO IL
60624-4027
US

IV. Provider business mailing address

55 E JACKSON BLVD STE 1500
CHICAGO IL
60604-4137
US

V. Phone/Fax

Practice location:
  • Phone: 773-826-1916
  • Fax:
Mailing address:
  • Phone: 312-663-1130
  • Fax: 312-663-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178012897
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: