Healthcare Provider Details

I. General information

NPI: 1285266775
Provider Name (Legal Business Name): MALINDA SPRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date: 10/30/2023
Reactivation Date: 11/07/2023

III. Provider practice location address

23950 PRADO LN
COLTON CA
92324-9734
US

IV. Provider business mailing address

23950 PRADO LN
COLTON CA
92324-9734
US

V. Phone/Fax

Practice location:
  • Phone: 909-514-1958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17112401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: