Provider Demographics
NPI:1598394009
Name:KOMOLTHITI, MALISA
Entity Type:Individual
Prefix:
First Name:MALISA
Middle Name:
Last Name:KOMOLTHITI
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 1:3865 GOLDEN MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-2635
Mailing Address - Country:US
Mailing Address - Phone:562-265-8222
Mailing Address - Fax:
Practice Address - Street 1:3865 GOLDEN MEADOW CT
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-2635
Practice Address - Country:US
Practice Address - Phone:562-265-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35002343A106H00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist