Provider Demographics
NPI:1407842172
Name:MALLOY, MICHEAL A (MSW)
Entity Type:Individual
Prefix:MR
First Name:MICHEAL
Middle Name:A
Last Name:MALLOY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-1624
Mailing Address - Country:US
Mailing Address - Phone:269-273-5000
Mailing Address - Fax:269-273-8019
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-1624
Practice Address - Country:US
Practice Address - Phone:269-273-5000
Practice Address - Fax:269-273-8019
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010331561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid
MI8008966800OtherBCBS
MI0656011Medicare ID - Type Unspecified