Basic Information
| Provider Information | |||||||||
| NPI: | 1215356381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TROJAN | ||||||||
| FirstName: | MALISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974231699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974231755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LSW.0009020489 | CO | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | CSW.09925179 | CO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6801100769 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8344898 | 05 | MI | MEDICAID |