Provider Demographics
NPI:1255613584
Name:MALCOLM, LISA MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:MALCOLM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:340 NE MAPLE
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163
Mailing Address - Country:US
Mailing Address - Phone:509-334-1133
Mailing Address - Fax:509-332-1608
Practice Address - Street 1:340 NE MAPLE
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163
Practice Address - Country:US
Practice Address - Phone:509-334-1133
Practice Address - Fax:509-332-1608
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA104100000X
104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker