Provider Demographics
NPI:1942271747
Name:GRESHAM, MALAYSIA HELENE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MALAYSIA
Middle Name:HELENE
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:LICSW
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Mailing Address - Street 1:2700 S 34TH ST
Mailing Address - Street 2:APT 315
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6045
Mailing Address - Country:US
Mailing Address - Phone:701-747-3190
Mailing Address - Fax:701-747-7340
Practice Address - Street 1:319TH MEDICAL GROUP
Practice Address - Street 2:1599 J STREET
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58205
Practice Address - Country:US
Practice Address - Phone:701-747-3190
Practice Address - Fax:701-747-7340
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDG103591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical