Provider Demographics
NPI:1346832250
Name:MALLAMO, PAUL DOUGLAS (LAC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DOUGLAS
Last Name:MALLAMO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4120
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-246-1008
Practice Address - Street 1:1009 E OLD HIGHWAY 56
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-4969
Practice Address - Country:US
Practice Address - Phone:913-764-7555
Practice Address - Fax:913-764-0739
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1677101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)