Basic Information
| Provider Information | |||||||||
| NPI: | 1407513070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALSOM | ||||||||
| FirstName: | DESIREE | ||||||||
| MiddleName: | CHARLOTTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 304 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403122897 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 HALLORAN PARK LANE | ||||||||
| Address2: | |||||||||
| City: | ST. CLAIRSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402965743 | ||||||||
| FaxNumber: | 7402965952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2021 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.