MEDICARE: SYDNEY MIKAYLA MALONE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225C00000X	Rehabilitation Counselor

General Provider Information

NPI Number	:	1104215755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY MIKAYLA MALONE

Provider Business Mailing Address
First Line	:	4515 S DURANGO DR APT 1033
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-6076
Country	:	US
Telephone Number	:	530-305-7246
Fax Number	:

Provider Business Practice Location Address
First Line	:	757 VISCANIO PL
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-7570
Country	:	US
Telephone Number	:	702-675-4953
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2015
Last Update Date	:	01/20/2015

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