Healthcare Provider Details

I. General information

NPI: 1508315219
Provider Name (Legal Business Name): BRITTANY MALAK LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 01/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 E WASHINGTON ST SUITE 2G
BLOOMINGTON IL
61701-4310
US

IV. Provider business mailing address

1312 N. LINDEN ST
BLOOMINGTON IL
61701
US

V. Phone/Fax

Practice location:
  • Phone: 630-301-8487
  • Fax:
Mailing address:
  • Phone: 630-301-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.001082
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: