Provider Demographics
NPI:1255566659
Name:MALCOLM, MARVA SIMMONS (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARVA
Middle Name:SIMMONS
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4434 RIBBLESDALE LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-2000
Mailing Address - Country:US
Mailing Address - Phone:407-421-1332
Mailing Address - Fax:
Practice Address - Street 1:6339 FOX BRIAR TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-1326
Practice Address - Country:US
Practice Address - Phone:407-421-1332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9923235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist