Provider Demographics
NPI:1689058273
Name:MALCOLM, LARISSA (LISW-S)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:144 E 194TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1030
Mailing Address - Country:US
Mailing Address - Phone:440-753-6287
Mailing Address - Fax:440-383-8874
Practice Address - Street 1:144 E 194TH ST
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1030
Practice Address - Country:US
Practice Address - Phone:216-789-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0026177104100000X
OHI.1700018-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker