Provider Demographics
NPI:1760439327
Name:O'MALLEY, SHEREEN M (MA, LP)
Entity Type:Individual
Prefix:
First Name:SHEREEN
Middle Name:M
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 STATION PARKWAYNW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-1719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1875 STATION PARKWAYNW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-1719
Practice Address - Country:US
Practice Address - Phone:763-482-9598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4846103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101760OtherUCARE
MN519252800Medicaid
MNHP18900OtherHEALTH PARTNERS
MN990991000633OtherPREFERRED ONE
MN483P10MOtherBCBS
MN62-02122OtherMEDICA