MEDICARE: MR. RIVER AZARIAH MALONE MA, LMFT-A

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	101YM0800X	Mental Health Counselor	MG61480134	WA

General Provider Information

NPI Number	:	1205607579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RIVER AZARIAH MALONE MA, LMFT-A

Provider Business Mailing Address
First Line	:	9611 KODIAK PL SW
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98367-6987
Country	:	US
Telephone Number	:	360-801-9837
Fax Number	:

Provider Business Practice Location Address
First Line	:	9611 KODIAK PL SW
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98367-6987
Country	:	US
Telephone Number	:	360-801-9837
Fax Number	:

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

Provider Enumeration Date	:	01/15/2024
Last Update Date	:	01/15/2024

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