Provider Demographics
NPI:1104990217
Name:MAHONEY, BETHANN (DO)
Entity type:Individual
Prefix:DR
First Name:BETHANN
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S HARBOR CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1319
Mailing Address - Country:US
Mailing Address - Phone:321-259-1662
Mailing Address - Fax:321-259-1223
Practice Address - Street 1:100 S HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1319
Practice Address - Country:US
Practice Address - Phone:321-259-1662
Practice Address - Fax:321-259-1223
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34362084P0800X, 2084P0802X
FLOS124072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H05908Medicare UPIN
Z77990Medicare ID - Type Unspecified