Provider Demographics
NPI:1457916215
Name:OMALLEY, MATTHEW (SLPA, ITDS)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:OMALLEY
Suffix:
Gender:M
Credentials:SLPA, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 DOMENICO CIR UNIT C14
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7813
Mailing Address - Country:US
Mailing Address - Phone:317-340-9490
Mailing Address - Fax:
Practice Address - Street 1:201 THORNBERRY BRANCH LN
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-3652
Practice Address - Country:US
Practice Address - Phone:317-340-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
FLSI38492355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No252Y00000XAgenciesEarly Intervention Provider Agency