Provider Demographics
NPI:1750614707
Name:MALCOM, STEPHANIE G (LCSW)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:G
Last Name:MALCOM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:GRABO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1030 WEST RD
Mailing Address - Street 2:
Mailing Address - City:BOWDOIN
Mailing Address - State:ME
Mailing Address - Zip Code:04287-7043
Mailing Address - Country:US
Mailing Address - Phone:207-841-7111
Mailing Address - Fax:
Practice Address - Street 1:65 TOPSHAM FAIR MALL RD STE 2
Practice Address - Street 2:
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-1763
Practice Address - Country:US
Practice Address - Phone:207-841-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC122361041C0700X
MELC130211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical