Provider Demographics
NPI:1598267809
Name:MALCOLM, LYDIA ROSA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:ROSA
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18459 PINES BLVD # 120
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1400
Mailing Address - Country:US
Mailing Address - Phone:954-715-5477
Mailing Address - Fax:
Practice Address - Street 1:9050 PINES BLVD STE 450-00
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6455
Practice Address - Country:US
Practice Address - Phone:954-715-5477
Practice Address - Fax:954-998-7177
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10094103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical