Provider Demographics
NPI:1922211036
Name:MALT, ILENE
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:MALT
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 1:1330 LINCOLN AVENUE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-454-2734
Mailing Address - Fax:415-454-2734
Practice Address - Street 1:1330 LINCOLN AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2120
Practice Address - Country:US
Practice Address - Phone:415-454-2734
Practice Address - Fax:415-454-2734
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS123711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical