Provider Demographics
NPI:1518333780
Name:MALCOLM, TARA-MARIE
Entity type:Individual
Prefix:MISS
First Name:TARA-MARIE
Middle Name:
Last Name:MALCOLM
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 1:11940 SW 12TH STREET
Mailing Address - Street 2:BUILDING 115
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025
Mailing Address - Country:US
Mailing Address - Phone:954-274-2057
Mailing Address - Fax:
Practice Address - Street 1:11940 SW 12TH ST
Practice Address - Street 2:BUILDING 115
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-5719
Practice Address - Country:US
Practice Address - Phone:954-274-2057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLBACB301120106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst