Provider Demographics
NPI:1730305350
Name:MALLETTE, LOUIS (LPC)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:MALLETTE
Suffix:
Gender:M
Credentials:LPC
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 457
Mailing Address - Street 2:
Mailing Address - City:GANADO
Mailing Address - State:AZ
Mailing Address - Zip Code:86505-0457
Mailing Address - Country:US
Mailing Address - Phone:928-755-4500
Mailing Address - Fax:
Practice Address - Street 1:STATE HWY SR 264 AND US 191
Practice Address - Street 2:
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505-0457
Practice Address - Country:US
Practice Address - Phone:928-755-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKLPC463101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid