1023504198 NPI number — AUSTIN JEROME MALONE LMHC

Table of content: AUSTIN JEROME MALONE LMHC (NPI 1023504198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023504198 NPI number — AUSTIN JEROME MALONE LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALONE
Provider First Name:
AUSTIN
Provider Middle Name:
JEROME
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023504198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 INDIANAPOLIS BLVD STE 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHERERVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46375-1275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-808-0793
Provider Business Mailing Address Fax Number:
765-274-0621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4905 MELTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46403-2873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-808-0793
Provider Business Practice Location Address Fax Number:
765-374-0761
Provider Enumeration Date:
07/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  39003046A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300014409 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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