Provider Demographics
NPI:1629050570
Name:DALE, MALINDA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MALINDA
Middle Name:ANN
Last Name:DALE
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 1:760 FLOWING WELL RD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-3126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 N JACKSON ST
Practice Address - Street 2:THE RENAISSANCE CENTRE
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2308
Practice Address - Country:US
Practice Address - Phone:229-889-7200
Practice Address - Fax:229-889-7393
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002619103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000966985AMedicaid
GA68BBGDSMedicare ID - Type Unspecified