=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679349567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DROP A JEWEL WITH MALAKA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2023
-----------------------------------------------------
Last Update Date | 11/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 162 MAIN ST STE 1
-----------------------------------------------------
City | BROCKTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02301-4013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-392-5525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 PERRY AVE
-----------------------------------------------------
City | BROCKTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02302-3606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-239-4475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGEMENT
-----------------------------------------------------
Name | MALAKA MIMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 508-239-4475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------