Healthcare Provider Details

I. General information

NPI: 1649480294
Provider Name (Legal Business Name): MICHELE MARIE MAHON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 HALF HOLLOW RD
DIX HILLS NY
11746-5861
US

IV. Provider business mailing address

197 HALF HOLLOW RD
DIX HILLS NY
11746-5861
US

V. Phone/Fax

Practice location:
  • Phone: 631-370-1622
  • Fax:
Mailing address:
  • Phone: 631-370-1622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number229850
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number229850
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: