Provider Demographics
NPI:1154906469
Name:MALLAH, CRISTAL (MA)
Entity type:Individual
Prefix:
First Name:CRISTAL
Middle Name:
Last Name:MALLAH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:KRISTELLE
Other - Middle Name:
Other - Last Name:MALLAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1213 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-8234
Mailing Address - Country:US
Mailing Address - Phone:215-776-5076
Mailing Address - Fax:
Practice Address - Street 1:100 S BROAD ST STE 1920
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19110-1064
Practice Address - Country:US
Practice Address - Phone:267-838-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MF001088106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty