Healthcare Provider Details

I. General information

NPI: 1174445175
Provider Name (Legal Business Name): JOHN MICHAEL O'MALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 BEARFOOT RD
NORTHBOROUGH MA
01532-1559
US

IV. Provider business mailing address

44 BEARFOOT RD
NORTHBOROUGH MA
01532-1559
US

V. Phone/Fax

Practice location:
  • Phone: 877-626-1815
  • Fax:
Mailing address:
  • Phone: 877-626-1815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: