Provider Demographics
NPI:1801149885
Name:MALCOLM, YANEQUE Y (M,S)
Entity type:Individual
Prefix:MISS
First Name:YANEQUE
Middle Name:Y
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:M,S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 W.OAKLAND PARK BLVD STE.200
Mailing Address - Street 2:LTERNATE FAMILY CARE
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351
Mailing Address - Country:US
Mailing Address - Phone:954-825-1650
Mailing Address - Fax:
Practice Address - Street 1:10001 W OAKLAND PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6925
Practice Address - Country:US
Practice Address - Phone:954-825-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH-8760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health