Healthcare Provider Details

I. General information

NPI: 1548712318
Provider Name (Legal Business Name): REBECCA MALIGNO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NW 23RD AVE BLDG 3 ST A
GAINESVILLE FL
32609
US

IV. Provider business mailing address

825 NW 23RD AVE BLDG 3
GAINESVILLE FL
32609-3574
US

V. Phone/Fax

Practice location:
  • Phone: 352-548-0250
  • Fax:
Mailing address:
  • Phone: 352-248-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW10721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: