Provider Demographics
NPI:1407513070
Name:MALSOM, DESIREE CHARLOTTE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:CHARLOTTE
Last Name:MALSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43759
Mailing Address - Country:US
Mailing Address - Phone:740-312-2897
Mailing Address - Fax:
Practice Address - Street 1:1 HALLORAN PARK LANE
Practice Address - Street 2:
Practice Address - City:ST. CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950
Practice Address - Country:US
Practice Address - Phone:740-296-5743
Practice Address - Fax:740-296-5952
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician