Healthcare Provider Details

I. General information

NPI: 1346159613
Provider Name (Legal Business Name): SHANE VERDERAME-MALACHOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 W CENTER STREET EXT
SOUTHINGTON CT
06489-2151
US

IV. Provider business mailing address

1103 W CENTER STREET EXT
SOUTHINGTON CT
06489-2151
US

V. Phone/Fax

Practice location:
  • Phone: 860-919-6794
  • Fax:
Mailing address:
  • Phone: 860-919-6794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number25228495
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: