Provider Demographics
NPI:1184011124
Name:WILLIAMS, MALISA (LCSW)
Entity Type:Individual
Prefix:
First Name:MALISA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MALISA
Other - Middle Name:
Other - Last Name:MORELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:5650 N DALSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1315
Mailing Address - Country:US
Mailing Address - Phone:208-912-4011
Mailing Address - Fax:208-939-5535
Practice Address - Street 1:1281 E IRON EAGLE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6599
Practice Address - Country:US
Practice Address - Phone:208-912-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-388381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1184011124Medicaid