Provider Demographics
NPI:1528272671
Name:MAHONEY, JANET LYNN (PT)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:LYNN
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 MARBLE RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2833
Mailing Address - Country:US
Mailing Address - Phone:517-896-8551
Mailing Address - Fax:517-337-1778
Practice Address - Street 1:4111 OKEMOS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3235
Practice Address - Country:US
Practice Address - Phone:517-896-8551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL538383174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501001955OtherPHYSICAL THERAPY LICENSE
MI650C313690OtherBCBS
MI0P25360Medicare ID - Type Unspecified