Healthcare Provider Details

I. General information

NPI: 1740859792
Provider Name (Legal Business Name): DIMITRI YERIK MALONEY CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

1200 N WHITE SANDS BLVD STE 121
ALAMOGORDO NM
88310-6774
US

V. Phone/Fax

Practice location:
  • Phone: 435-862-4913
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: