Provider Demographics
NPI:1164032488
Name:MALVAL, MARIESARAH KRISTELLE
Entity Type:Individual
Prefix:
First Name:MARIESARAH KRISTELLE
Middle Name:
Last Name:MALVAL
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 1:11831 SW 102ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-2748
Mailing Address - Country:US
Mailing Address - Phone:786-205-3703
Mailing Address - Fax:
Practice Address - Street 1:11831 SW 102ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2748
Practice Address - Country:US
Practice Address - Phone:786-205-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-01
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1493103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty