Healthcare Provider Details

I. General information

NPI: 1194720367
Provider Name (Legal Business Name): MICHAEL STEPHEN MALLAHAN AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15906 MILL CREEK BLVD SUITE 102
MILL CREEK WA
98012-1797
US

IV. Provider business mailing address

15906 MILL CREEK BLVD SUITE 102
MILL CREEK WA
98012-1797
US

V. Phone/Fax

Practice location:
  • Phone: 425-225-2626
  • Fax: 425-225-2634
Mailing address:
  • Phone: 425-225-2626
  • Fax: 425-225-2634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberLD0001117
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License NumberLD00001117
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License NumberLD00001117
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberLD00001117
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: