Provider Demographics
NPI:1831120690
Name:O'MALLEY, CHARLES GERALD (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GERALD
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4661 CATHY AVE
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-4213
Mailing Address - Country:US
Mailing Address - Phone:714-761-7091
Mailing Address - Fax:714-761-7019
Practice Address - Street 1:4401 ATLANTIC AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2218
Practice Address - Country:US
Practice Address - Phone:562-984-2044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9874103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 9874OtherPSYCHOLOGIST LICENSE