Provider Demographics
NPI:1801984422
Name:MALLAS, ALAN W
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:W
Last Name:MALLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:R 11 ANDOVER STREET
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960
Mailing Address - Country:US
Mailing Address - Phone:978-532-1428
Mailing Address - Fax:
Practice Address - Street 1:27 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-7309
Practice Address - Country:US
Practice Address - Phone:978-745-8890
Practice Address - Fax:978-741-3104
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1021060101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)