Provider Demographics
NPI:1184371031
Name:O'MALLEY, DONNA MAE (LADC)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MAE
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 GATEWAY DR NE STE 1
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-1621
Mailing Address - Country:US
Mailing Address - Phone:218-230-0787
Mailing Address - Fax:
Practice Address - Street 1:210 GATEWAY DR NE STE 4
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1621
Practice Address - Country:US
Practice Address - Phone:218-230-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional