Provider Demographics
NPI:1013403880
Name:MALONE, SHAYNE
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:
Last Name:MALONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11406 LYNDENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-5263
Mailing Address - Country:US
Mailing Address - Phone:615-294-1221
Mailing Address - Fax:
Practice Address - Street 1:2444 COMMERCE RD STE 215
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7560
Practice Address - Country:US
Practice Address - Phone:615-294-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-59119103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst