Provider Demographics
NPI:1861097156
Name:MALLIA, ANTHONY JAMES (MSCP)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JAMES
Last Name:MALLIA
Suffix:
Gender:M
Credentials:MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 HOOP POLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28512-5812
Mailing Address - Country:US
Mailing Address - Phone:248-396-4861
Mailing Address - Fax:
Practice Address - Street 1:32100 TELEGRAPH RD STE 205
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2454
Practice Address - Country:US
Practice Address - Phone:248-712-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2025-02-10
Deactivation Date:2025-01-09
Deactivation Code:
Reactivation Date:2025-01-16
Provider Licenses
StateLicense IDTaxonomies
SC10235101YM0800X
106S00000X, 156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician