Healthcare Provider Details

I. General information

NPI: 1104691104
Provider Name (Legal Business Name): BETHANY MALONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1868 TULLAGEE AVE
MELBOURNE FL
32940-6037
US

IV. Provider business mailing address

1868 TULLAGEE AVE
MELBOURNE FL
32940-6037
US

V. Phone/Fax

Practice location:
  • Phone: 347-727-8314
  • Fax:
Mailing address:
  • Phone: 347-727-8314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: