Provider Demographics
NPI:1124254487
Name:MAHONE, MICHELLE C (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:C
Last Name:MAHONE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:MICHELE
Other - Middle Name:C
Other - Last Name:LUDWIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:769 CALLA AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1335
Mailing Address - Country:US
Mailing Address - Phone:619-246-2014
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:619-692-0727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004815103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicare UPIN