Healthcare Provider Details

I. General information

NPI: 1841672052
Provider Name (Legal Business Name): MICHAEL MAHONEY JR. M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13890 BRADDOCK RD STE. 207
CENTREVILLE VA
20121-2435
US

IV. Provider business mailing address

45410 MALLARD ST
STERLING VA
20165-2527
US

V. Phone/Fax

Practice location:
  • Phone: 540-720-2261
  • Fax: 540-720-5660
Mailing address:
  • Phone: 703-955-6983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202007902
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: