Provider Demographics
NPI:1992936371
Name:MALLETTE, MICHAEL (CASAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MALLETTE
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 HOMER CLAYTON DR
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-2207
Mailing Address - Country:US
Mailing Address - Phone:256-582-3203
Mailing Address - Fax:256-582-3216
Practice Address - Street 1:22165 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-8994
Practice Address - Country:US
Practice Address - Phone:256-582-4465
Practice Address - Fax:256-582-5339
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9984101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)