Healthcare Provider Details

I. General information

NPI: 1861097156
Provider Name (Legal Business Name): ANTHONY JAMES MALLIA MSCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date: 01/09/2025
Reactivation Date: 01/16/2025

III. Provider practice location address

32100 TELEGRAPH RD STE 205
BINGHAM FARMS MI
48025-2454
US

IV. Provider business mailing address

126 HOOP POLE CREEK DR
ATLANTIC BEACH NC
28512-5812
US

V. Phone/Fax

Practice location:
  • Phone: 248-712-4266
  • Fax:
Mailing address:
  • Phone: 248-396-4861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10235
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: