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General NPI Number Information
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NPI Number | 1649803594
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Entity Type | Individual
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Provider Name | MALCOLM IAN BERNARD LPC
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Gender | Male
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Dates
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Enumeration Date | 02/19/2020
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Last Update Date | 10/30/2023
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Provider Practice Location Address
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Address Line | 1320 CENTRAL PARK BLVD STE 200
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City | FREDERICKSBURG
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State | VA
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Zip | 22401-4953
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Country | US
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Telephone | 540-709-1778
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Fax | 540-227-7050
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Provider Business Mailing Address
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Address Line | 800 BATTERY AVE SE STE 100
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City | ATLANTA
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State | GA
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Zip | 30339-5107
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Country | US
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Telephone | 540-709-1778
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Fax | 540-227-7050
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701008236
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License Number State | VA
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