Provider Demographics
NPI:1306065438
Name:O'MALLEY, LEIGH (MA)
Entity type:Individual
Prefix:MR
First Name:LEIGH
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:CATHLAMET
Mailing Address - State:WA
Mailing Address - Zip Code:98612-0154
Mailing Address - Country:US
Mailing Address - Phone:360-795-8630
Mailing Address - Fax:360-795-6224
Practice Address - Street 1:42 ELOCHOMAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9602
Practice Address - Country:US
Practice Address - Phone:360-795-8630
Practice Address - Fax:360-795-6224
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00008157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH00008157OtherMENTAL HEALTH COUNSELOR