Provider Demographics
NPI:1417263609
Name:MAHONEY, MARTIN JAMES (AUD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:JAMES
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-9606
Mailing Address - Country:US
Mailing Address - Phone:810-721-7274
Mailing Address - Fax:810-721-7275
Practice Address - Street 1:1141 S STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1964
Practice Address - Country:US
Practice Address - Phone:810-412-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000561231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640E801070OtherBCBS