Healthcare Provider Details

I. General information

NPI: 1952425449
Provider Name (Legal Business Name): MARY ELIZABETH MAHONEY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MAIN ST
SACO ME
04072-3509
US

IV. Provider business mailing address

45 SUMMER ST UNIT 3
KENNEBUNK ME
04043-6636
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC3106
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: