Provider Demographics
NPI:1043806409
Name:MALKOVA, TETIANA
Entity Type:Individual
Prefix:
First Name:TETIANA
Middle Name:
Last Name:MALKOVA
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 1:320 PARKWOOD AVE APT 1306
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-3565
Mailing Address - Country:US
Mailing Address - Phone:704-451-1967
Mailing Address - Fax:
Practice Address - Street 1:311 WILLIAMSON RD STE 103
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5967
Practice Address - Country:US
Practice Address - Phone:704-360-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16083101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional