Provider Demographics
NPI:1407504061
Name:COLSTON, MALIK
Entity Type:Individual
Prefix:
First Name:MALIK
Middle Name:
Last Name:COLSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7735 NW 48TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5547
Mailing Address - Country:US
Mailing Address - Phone:786-860-5161
Mailing Address - Fax:
Practice Address - Street 1:7735 NW 48TH ST STE 110
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-5547
Practice Address - Country:US
Practice Address - Phone:786-860-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician