Provider Demographics
NPI:1740651884
Name:O'MALLEY, MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 ELLSWORTH ST APT 117
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-2516
Mailing Address - Country:US
Mailing Address - Phone:203-850-3130
Mailing Address - Fax:
Practice Address - Street 1:982 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1913
Practice Address - Country:US
Practice Address - Phone:203-696-3260
Practice Address - Fax:203-683-3630
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0085341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical