Provider Demographics
NPI:1164979407
Name:OMALLEY, THERESA (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:OMALLEY
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2508
Mailing Address - Country:US
Mailing Address - Phone:617-571-4894
Mailing Address - Fax:
Practice Address - Street 1:200F MAIN ST
Practice Address - Street 2:SUITE 144
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1619
Practice Address - Country:US
Practice Address - Phone:857-800-6407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-03
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3222235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA01102717OtherASHA