Provider Demographics
NPI:1740498195
Name:MALOUFF, MARTIN MOSE (BS CACIII)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:MOSE
Last Name:MALOUFF
Suffix:
Gender:M
Credentials:BS CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 533
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-0533
Mailing Address - Country:US
Mailing Address - Phone:719-859-0483
Mailing Address - Fax:
Practice Address - Street 1:1004 S CARBON AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-3664
Practice Address - Country:US
Practice Address - Phone:719-846-4481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCACIII #6383101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)