Provider Demographics
NPI:1821098591
Name:MALOTT, MICHELE D (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:D
Last Name:MALOTT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MAIN ST
Mailing Address - Street 2:SUITE 411
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-5810
Mailing Address - Country:US
Mailing Address - Phone:541-850-5871
Mailing Address - Fax:541-850-9430
Practice Address - Street 1:905 MAIN ST
Practice Address - Street 2:SUITE 411
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-5810
Practice Address - Country:US
Practice Address - Phone:541-850-5871
Practice Address - Fax:541-850-9430
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL3624101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL3624OtherLCSW
OR129861Medicaid