MEDICARE: THE MAHOGANY PROJEK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1053891333
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MAHOGANY PROJEK, LLC

Provider Business Mailing Address
First Line	:	4012 SPRING MEADOW CRES
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-3118
Country	:	US
Telephone Number	:	323-823-8682
Fax Number	:

Provider Business Practice Location Address
First Line	:	4012 SPRING MEADOW CRES
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-3118
Country	:	US
Telephone Number	:	323-823-8628
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHARDE' O'ROURKE
Credential	:	LPC, CCTP, LSATP
Telephone Number	:	323-823-8628

Provider Enumeration Date	:	08/16/2018
Last Update Date	:	08/16/2018

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