Healthcare Provider Details

I. General information

NPI: 1730846478
Provider Name (Legal Business Name): MAHOGANY BRIDGES MENTAL HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 SOUTH DIXIE DRIVE SUITE 102
DAYTON OH
45409
US

IV. Provider business mailing address

743 KNICKERBOCKER AVE
SPRINGFIELD OH
45506-3319
US

V. Phone/Fax

Practice location:
  • Phone: 330-518-2888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARQUITA THOMPSON
Title or Position: CEO
Credential:
Phone: 330-518-2888