Provider Demographics
NPI:1407118664
Name:MALCOMSON, KATHLEEN (MS ED)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:MALCOMSON
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3446 76TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-2269
Mailing Address - Country:US
Mailing Address - Phone:718-424-5110
Mailing Address - Fax:
Practice Address - Street 1:3446 76TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-2269
Practice Address - Country:US
Practice Address - Phone:718-424-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist