Healthcare Provider Details

I. General information

NPI: 1730351370
Provider Name (Legal Business Name): MALVERN C HOLLAND JR. ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 ALTA ROAD R.J. DONOVAN CORRECTIONAL FACILITY
SAN DIEGO CA
92179-0001
US

IV. Provider business mailing address

PO BOX 80132
SAN DIEGO CA
92138-0132
US

V. Phone/Fax

Practice location:
  • Phone: 619-955-2622
  • Fax:
Mailing address:
  • Phone: 619-955-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY21206
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY21206
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21206
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY21206
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License NumberPSY21206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: