Basic Information
| Provider Information | |||||||||
| NPI: | 1659481166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALONEY | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015500040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089097799 | ||||||||
| FaxNumber: | 5087642432 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 PINE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015501823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087659167 | ||||||||
| FaxNumber: | 5087642462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 246964 | MA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 246964 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 110088988A | 05 | MA | MEDICAID |