Healthcare Provider Details

I. General information

NPI: 1801384300
Provider Name (Legal Business Name): MARISA GLORIA MALONE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3011
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-4698
  • Fax: 585-922-5702
Mailing address:
  • Phone: 585-922-4698
  • Fax: 585-922-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number023927
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: