Healthcare Provider Details

I. General information

NPI: 1053425793
Provider Name (Legal Business Name): JUNE SHORTLEY MALONE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE NEW MEXICO VA HEALTH CARE SYSTEM (BHCL 116)
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

6908 NACELLE RD NE
RIO RANCHO NM
87144-3562
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-2819
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-256-2819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1708-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: