Provider Demographics
NPI:1033235544
Name:LIGHT, MALCOLM H II (MA)
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:H
Last Name:LIGHT
Suffix:II
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14171 METROPOLIS AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4335
Mailing Address - Country:US
Mailing Address - Phone:239-936-0721
Mailing Address - Fax:
Practice Address - Street 1:14171 METROPOLIS AVE STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4335
Practice Address - Country:US
Practice Address - Phone:239-936-0721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY530231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist