=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497479174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN MALOTT LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2022
-----------------------------------------------------
Last Update Date | 09/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1612 WEDGEWOOD PLAZA DR
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-570-5429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1166 E BLUE HERON BLVD
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-842-8135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH21105
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------