Provider Demographics
NPI:1710205596
Name:O'MALLEY, MICJHAEL PATRICK (LADAC)
Entity Type:Individual
Prefix:MR
First Name:MICJHAEL
Middle Name:PATRICK
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:RADIUM SPRINGS
Mailing Address - State:NM
Mailing Address - Zip Code:88054-0373
Mailing Address - Country:US
Mailing Address - Phone:575-621-9660
Mailing Address - Fax:
Practice Address - Street 1:715 E IDAHO AVE
Practice Address - Street 2:4B
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-4703
Practice Address - Country:US
Practice Address - Phone:575-524-2505
Practice Address - Fax:575-524-2504
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLADAC3619101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMLADAC3619OtherLICENSE NUMBER