Provider Demographics
NPI:1457727414
Name:OMALLEY, AERIN ALEX
Entity Type:Individual
Prefix:
First Name:AERIN
Middle Name:ALEX
Last Name:OMALLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 S STATE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5858
Mailing Address - Country:US
Mailing Address - Phone:707-489-8002
Mailing Address - Fax:
Practice Address - Street 1:776 S STATE ST STE 107
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5858
Practice Address - Country:US
Practice Address - Phone:707-489-8002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT114059101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health