Provider Demographics
NPI:1922064104
Name:MALOTT, RONALD J (LADAC)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:J
Last Name:MALOTT
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:RR 1 BOX 56A
Mailing Address - Street 2:
Mailing Address - City:SPRINGER
Mailing Address - State:NM
Mailing Address - Zip Code:87747-9703
Mailing Address - Country:US
Mailing Address - Phone:575-483-2480
Mailing Address - Fax:
Practice Address - Street 1:213 N. 2ND STREET
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740
Practice Address - Country:US
Practice Address - Phone:575-445-9761
Practice Address - Fax:575-445-2887
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3757101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)