Healthcare Provider Details

I. General information

NPI: 1043886930
Provider Name (Legal Business Name): MATTHEW MALCOLM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 BROOKTREE RD STE 101
WEXFORD PA
15090-9278
US

IV. Provider business mailing address

2500 BROOKTREE RD STE 101
WEXFORD PA
15090-9278
US

V. Phone/Fax

Practice location:
  • Phone: 412-230-8615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH007312
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB843445
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: