Provider Demographics
NPI:1811385073
Name:LORETTA S. MALTA, PH.D.
Entity Type:Organization
Organization Name:LORETTA S. MALTA, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MALTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:518-419-7716
Mailing Address - Street 1:76 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1733
Mailing Address - Country:US
Mailing Address - Phone:518-419-7716
Mailing Address - Fax:
Practice Address - Street 1:747 MADISON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3809
Practice Address - Country:US
Practice Address - Phone:518-419-7716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016294103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty