Provider Demographics
NPI:1316690829
Name:MAILLOUX, MICHAEL JOSEPH
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MAILLOUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21831 133RD RD FL 1
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1622
Mailing Address - Country:US
Mailing Address - Phone:757-322-0785
Mailing Address - Fax:
Practice Address - Street 1:21831 133RD RD FL 1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-1622
Practice Address - Country:US
Practice Address - Phone:757-322-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06966300101YM0800X, 104100000X
NY120693101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health