Healthcare Provider Details

I. General information

NPI: 1730305350
Provider Name (Legal Business Name): LOUIS MALLETTE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE HWY SR 264 AND US 191
GANADO AZ
86505-0457
US

IV. Provider business mailing address

PO BOX 457
GANADO AZ
86505-0457
US

V. Phone/Fax

Practice location:
  • Phone: 928-755-4500
  • Fax:
Mailing address:
  • Phone: 928-755-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC463
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: