Provider Demographics
NPI:1427654805
Name:MUNSON, MALVIN DOUGLAS
Entity type:Individual
Prefix:MR
First Name:MALVIN
Middle Name:DOUGLAS
Last Name:MUNSON
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 1:220 GALA CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-2012
Mailing Address - Country:US
Mailing Address - Phone:386-576-6332
Mailing Address - Fax:
Practice Address - Street 1:220 GALA CIR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-2012
Practice Address - Country:US
Practice Address - Phone:386-576-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14492103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3684Medicaid