Provider Demographics
NPI:1225852973
Name:MALONEY, MATTHEW (SAC IT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MALONEY
Suffix:
Gender:M
Credentials:SAC IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 GERSHWIN DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4328
Mailing Address - Country:US
Mailing Address - Phone:920-391-4700
Mailing Address - Fax:920-391-4731
Practice Address - Street 1:3150 GERSHWIN DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4328
Practice Address - Country:US
Practice Address - Phone:920-391-4700
Practice Address - Fax:920-391-4731
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19746101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)