Provider Demographics
NPI:1457109209
Name:MALCOM, SARA MARIE (THERAPIST)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:MALCOM
Suffix:
Gender:F
Credentials:THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4277 E YELLOWSTONE PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-0510
Mailing Address - Country:US
Mailing Address - Phone:712-898-3185
Mailing Address - Fax:
Practice Address - Street 1:4700 GORDON DR STE 202
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-1911
Practice Address - Country:US
Practice Address - Phone:612-227-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA122115101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health