Provider Demographics
NPI:1962617811
Name:MAHALICK, DAVID M (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:MAHALICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:D
Other - Middle Name:M
Other - Last Name:MAHALICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2066 MILLBURN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3727
Mailing Address - Country:US
Mailing Address - Phone:973-313-9393
Mailing Address - Fax:973-313-1666
Practice Address - Street 1:2066 MILLBURN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3727
Practice Address - Country:US
Practice Address - Phone:908-832-6629
Practice Address - Fax:973-313-1666
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2582103G00000X
NY013948DUP103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA580940Medicare ID - Type UnspecifiedMEDICARE REIMBURSEMENT NU
NJ67604980FMedicare UPIN