Healthcare Provider Details

I. General information

NPI: 1174137962
Provider Name (Legal Business Name): MALIK HOLMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CEDAR HILL ST
MARLBOROUGH MA
01752-5900
US

IV. Provider business mailing address

14220 S NORMAL AVE
RIVERDALE IL
60827-2309
US

V. Phone/Fax

Practice location:
  • Phone: 508-658-2105
  • Fax:
Mailing address:
  • Phone: 708-802-1946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: