Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003055187 |
---|---|
Provider Name | Louis Mallette SR. |
First Address | Bethel, AK 99559-0528 |
Second Address | Bethel, AK 99559 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2009 |
Last Update Date | 12/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DA4442 | (05) | AK |