Healthcare Provider Details

I. General information

NPI: 1174200463
Provider Name (Legal Business Name): NICK A. MAHAFFEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8831 SR 785
HILLSBORO OH
45133
US

IV. Provider business mailing address

8812 W BERRYSVILLE RD
HILLSBORO OH
45133-6068
US

V. Phone/Fax

Practice location:
  • Phone: 937-764-1134
  • Fax:
Mailing address:
  • Phone: 937-205-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: