Healthcare Provider Details

I. General information

NPI: 1902279284
Provider Name (Legal Business Name): EVADNE MALONE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 MURRELL RD STE 100
MELBOURNE FL
32940-6700
US

IV. Provider business mailing address

175 MIDDLE ST UNIT 1201
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 321-426-7759
  • Fax: 321-593-0839
Mailing address:
  • Phone: 866-610-0580
  • Fax: 407-588-6824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-23556
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: