Provider Demographics
NPI:1497498331
Name:MALCOM, MINDI LEE
Entity Type:Individual
Prefix:
First Name:MINDI
Middle Name:LEE
Last Name:MALCOM
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 1:14600 FARM TO MARKET ROAD 1173
Mailing Address - Street 2:
Mailing Address - City:KRUM
Mailing Address - State:TX
Mailing Address - Zip Code:76249
Mailing Address - Country:US
Mailing Address - Phone:940-300-4840
Mailing Address - Fax:
Practice Address - Street 1:14600 FARM TO MARKET ROAD 1173
Practice Address - Street 2:
Practice Address - City:KRUM
Practice Address - State:TX
Practice Address - Zip Code:76249
Practice Address - Country:US
Practice Address - Phone:940-300-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional