Basic Information
| Provider Information | |||||||||
| NPI: | 1033636519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLOY | ||||||||
| FirstName: | BLAKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 13603 80TH CIR N | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553698961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632743120 | ||||||||
| FaxNumber: | 7632743121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2017 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.