Provider Demographics
NPI:1982177689
Name:MALIK, THAD
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:
Last Name:MALIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1243
Mailing Address - Country:US
Mailing Address - Phone:248-825-5715
Mailing Address - Fax:
Practice Address - Street 1:1708 SEQUOIA DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1243
Practice Address - Country:US
Practice Address - Phone:248-825-5715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9685638253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency