Provider Demographics
NPI:1821227604
Name:OMALLOY, MARY ANN (DC, PCC-S, LICDC)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:OMALLOY
Suffix:
Gender:F
Credentials:DC, PCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 ELLA ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45223-2035
Mailing Address - Country:US
Mailing Address - Phone:513-225-6977
Mailing Address - Fax:
Practice Address - Street 1:1722 ELLA ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45223-2035
Practice Address - Country:US
Practice Address - Phone:513-225-6977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH943881101YA0400X
OHPCC-S101YP2500X
OH3419111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No111NI0900XChiropractic ProvidersChiropractorInternist