Provider Demographics
NPI:1801207899
Name:MALSOM, ERIKA LYNN (MFT-INTERN)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:LYNN
Last Name:MALSOM
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:MENDOCINO COAST HOSPITALITY CENTER
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437
Mailing Address - Country:US
Mailing Address - Phone:707-961-0172
Mailing Address - Fax:844-388-6167
Practice Address - Street 1:137 E OAK STREET
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-961-0172
Practice Address - Fax:844-388-6167
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92589225C00000X
101Y00000X
CAMFC41677251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101Y00000XBehavioral Health & Social Service ProvidersCounselor