Provider Demographics
NPI:1649360066
Name:MALDAVER, MARSHALL DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:DAVID
Last Name:MALDAVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1142
Mailing Address - Country:US
Mailing Address - Phone:248-674-3382
Mailing Address - Fax:
Practice Address - Street 1:4950 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1142
Practice Address - Country:US
Practice Address - Phone:248-674-3382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006412103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF33053OtherBCBSM
MI120497OtherVALUE OPTIONS
R66824Medicare UPIN
MI120497OtherVALUE OPTIONS