Provider Demographics
NPI:1124335997
Name:MAHONEY, KEVIN (PT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:401-330-1437
Mailing Address - Fax:401-330-1447
Practice Address - Street 1:1 KETTLE POINT AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5375
Practice Address - Country:US
Practice Address - Phone:401-330-1437
Practice Address - Fax:401-330-1447
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI001846202Medicare PIN