Healthcare Provider Details

I. General information

NPI: 1093762528
Provider Name (Legal Business Name): LISA A. MALCOLM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 COUNTY RD
POCASSET MA
02559-2110
US

IV. Provider business mailing address

32 KIMBERLY WAY
COTUIT MA
02635-2423
US

V. Phone/Fax

Practice location:
  • Phone: 508-564-9637
  • Fax: 508-280-5308
Mailing address:
  • Phone: 508-280-5308
  • Fax: 508-280-5308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1022268
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: