MEDICARE: SANDRA GERMAIN MALONE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	3714	MN

General Provider Information

NPI Number	:	1174645220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA GERMAIN MALONE

Provider Business Mailing Address
First Line	:	701 PARK AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55415-1623
Country	:	US
Telephone Number	:	612-873-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2714 HIGHWAY 88
Second Line	:
City	:	SAINT ANTHONY
State	:	MN
Zip	:	55418-3266
Country	:	US
Telephone Number	:	612-873-6963
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	04/08/2024

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