Provider Demographics
NPI:1104298298
Name:MICHAEL VALALIK PMHNP BC
Entity type:Organization
Organization Name:MICHAEL VALALIK PMHNP BC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VALALIK
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:203-640-1563
Mailing Address - Street 1:PO BOX 2486
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-0034
Mailing Address - Country:US
Mailing Address - Phone:203-640-1563
Mailing Address - Fax:203-774-1161
Practice Address - Street 1:770 SAYBROOK RD BLDG B
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4739
Practice Address - Country:US
Practice Address - Phone:203-640-1563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6276363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1669841987OtherINDIVIDUAL NPI NUMBER