Provider Demographics
NPI:1306404074
Name:MALYNE, IVA N
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:N
Last Name:MALYNE
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 1:3601 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5356
Mailing Address - Country:US
Mailing Address - Phone:586-722-7253
Mailing Address - Fax:586-722-7257
Practice Address - Street 1:3601 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5356
Practice Address - Country:US
Practice Address - Phone:586-722-7253
Practice Address - Fax:586-722-7257
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011045671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical