Provider Demographics
NPI:1447929724
Name:MALCOLM, AVERILLE BC
Entity type:Individual
Prefix:
First Name:AVERILLE
Middle Name:BC
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 1:6130 217TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2234
Mailing Address - Country:US
Mailing Address - Phone:917-362-7309
Mailing Address - Fax:
Practice Address - Street 1:6130 217TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-2234
Practice Address - Country:US
Practice Address - Phone:917-362-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113628104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty