Provider Demographics
NPI:1174663504
Name:O'MALLEY, ELLEN (LMHC)
Entity Type:Individual
Prefix:MISS
First Name:ELLEN
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12350 WOODROSE CT APT 3
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4621
Mailing Address - Country:US
Mailing Address - Phone:239-822-6718
Mailing Address - Fax:
Practice Address - Street 1:12350 WOODROSE CT APT 3
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4621
Practice Address - Country:US
Practice Address - Phone:239-822-6718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 6031101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760418100Medicaid