Basic Information
| Provider Information | |||||||||
| NPI: | 1811669062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALCOLM | ||||||||
| FirstName: | GAVIN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4310 METRO PKWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339169416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392232751 | ||||||||
| FaxNumber: | 2395612933 | ||||||||
| Practice Location | |||||||||
| Address1: | 12989 SOUTHERN BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334709205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615136716 | ||||||||
| FaxNumber: | 5616608472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW7693 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.