Provider Demographics
NPI:1356823223
Name:MALCOLM, ASHLEY R (LMT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:R
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7165
Mailing Address - Country:US
Mailing Address - Phone:717-270-9798
Mailing Address - Fax:
Practice Address - Street 1:1000 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042
Practice Address - Country:US
Practice Address - Phone:717-644-3342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG012533225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist