Healthcare Provider Details

I. General information

NPI: 1477804714
Provider Name (Legal Business Name): DIANA H. MALKIN M.ED., CAGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 PLANTATION ST
WORCESTER MA
01604-3069
US

IV. Provider business mailing address

149 RICHMOND AVE
WORCESTER MA
01602-1541
US

V. Phone/Fax

Practice location:
  • Phone: 508-849-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number463388
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: