Provider Demographics
NPI:1750439469
Name:MAILLOUX, PAUL MICHAEL (MSW)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:MAILLOUX
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W MICHIGAN AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-5840
Mailing Address - Country:US
Mailing Address - Phone:269-217-2784
Mailing Address - Fax:269-743-4199
Practice Address - Street 1:4200 W MICHIGAN AVE
Practice Address - Street 2:SUITE 245
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5892
Practice Address - Country:US
Practice Address - Phone:269-217-2784
Practice Address - Fax:269-585-6153
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010341081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP29330Medicare ID - Type UnspecifiedMEDICARE PART B