Provider Demographics
NPI:1346270196
Name:MALIS, JOHN GORDON (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GORDON
Last Name:MALIS
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 WATER ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-3040
Mailing Address - Country:US
Mailing Address - Phone:978-463-6929
Mailing Address - Fax:978-463-4626
Practice Address - Street 1:184 STATE ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-6637
Practice Address - Country:US
Practice Address - Phone:978-463-6929
Practice Address - Fax:978-463-4626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10193951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1891367Medicaid
MAPO5651Medicare ID - Type Unspecified