Provider Demographics
NPI:1679979868
Name:MALONE, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MALONE
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:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-0264
Mailing Address - Country:US
Mailing Address - Phone:505-906-5291
Mailing Address - Fax:
Practice Address - Street 1:1000 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5509
Practice Address - Country:US
Practice Address - Phone:505-721-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-089611041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool