Healthcare Provider Details

I. General information

NPI: 1760305247
Provider Name (Legal Business Name): EVGENY MALTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 RICHMOND HWY
ALEXANDRIA VA
22309-2425
US

IV. Provider business mailing address

8405 RICHMOND HWY
ALEXANDRIA VA
22309-2425
US

V. Phone/Fax

Practice location:
  • Phone: 703-896-0760
  • Fax:
Mailing address:
  • Phone: 703-896-0760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2835926
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: