Provider Demographics
NPI:1174645220
Name:MALONE, SANDRA GERMAIN
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:GERMAIN
Last Name:MALONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:JOAN
Other - Last Name:GERMAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-3000
Mailing Address - Fax:
Practice Address - Street 1:2714 HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-3266
Practice Address - Country:US
Practice Address - Phone:612-873-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3714103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist