Provider Demographics
NPI:1801067061
Name:MALCOLM, GENEVIEVE
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 MACOM DR STE 103
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-9256
Mailing Address - Country:US
Mailing Address - Phone:630-904-4327
Mailing Address - Fax:630-904-4373
Practice Address - Street 1:1308 MACOM DR STE 103
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-9256
Practice Address - Country:US
Practice Address - Phone:630-848-9665
Practice Address - Fax:630-904-4373
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001298231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist