Provider Demographics
NPI:1942343587
Name:MALOY, MICHAEL JOSEPH (LPN, CACIII, NCACI)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MALOY
Suffix:
Gender:M
Credentials:LPN, CACIII, NCACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 N ASH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3201
Mailing Address - Country:US
Mailing Address - Phone:970-565-4109
Mailing Address - Fax:970-565-8804
Practice Address - Street 1:35 N ASH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3201
Practice Address - Country:US
Practice Address - Phone:970-565-4109
Practice Address - Fax:970-565-8804
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5503101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37129368Medicaid