Provider Demographics
NPI:1114220837
Name:MALOTT, TRISHA P (LCSW)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:P
Last Name:MALOTT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19642
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9642
Mailing Address - Country:US
Mailing Address - Phone:217-545-8229
Mailing Address - Fax:217-545-2275
Practice Address - Street 1:901 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4833
Practice Address - Country:US
Practice Address - Phone:217-545-8229
Practice Address - Fax:217-545-2275
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490136151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL256514008Medicare PIN