Provider Demographics
NPI:1871783951
Name:MAHON, BRENDA LEE (OTD/OTR)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:MAHON
Suffix:
Gender:
Credentials:OTD/OTR
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:LEE
Other - Last Name:DIGIROLAMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:563 SEVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-9037
Mailing Address - Country:US
Mailing Address - Phone:570-228-5111
Mailing Address - Fax:
Practice Address - Street 1:350 CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5993
Practice Address - Country:US
Practice Address - Phone:386-868-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
NY0193350225XG0600X
PAOC011466225XG0600X
NJ46TR00529000225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR00529000OtherPROFESSIONAL LICENSE