Healthcare Provider Details

I. General information

NPI: 1508078064
Provider Name (Legal Business Name): MARY MAHONEY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19805 SUMTER WAY
POOLESVILLE MD
20837-2231
US

IV. Provider business mailing address

19805 SUMTER WAY
POOLESVILLE MD
20837-2231
US

V. Phone/Fax

Practice location:
  • Phone: 301-972-8518
  • Fax:
Mailing address:
  • Phone: 301-972-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC0061
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: