Provider Demographics
NPI:1821621335
Name:MALARIK, TERA MARIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:MARIE
Last Name:MALARIK
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 CHESTNUT RD
Mailing Address - Street 2:
Mailing Address - City:MOLINO
Mailing Address - State:FL
Mailing Address - Zip Code:32577-6039
Mailing Address - Country:US
Mailing Address - Phone:850-619-9518
Mailing Address - Fax:
Practice Address - Street 1:1040 GULF BREEZE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7808
Practice Address - Country:US
Practice Address - Phone:850-619-9518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLAL62872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program