Provider Demographics
NPI:1922617877
Name:MALKASIAN, MARIA R (SUDPT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:R
Last Name:MALKASIAN
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0072
Mailing Address - Country:US
Mailing Address - Phone:360-452-4062
Mailing Address - Fax:360-452-4189
Practice Address - Street 1:3430 E HIGHWAY 101 STE 3
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-9069
Practice Address - Country:US
Practice Address - Phone:360-452-4062
Practice Address - Fax:360-452-4189
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61081882261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder