Provider Demographics
NPI:1689930992
Name:MALCOM, AMANDA (LPC-INTERN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MALCOM
Suffix:
Gender:F
Credentials:LPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10117
Mailing Address - Street 2:
Mailing Address - City:RIVER OAKS
Mailing Address - State:TX
Mailing Address - Zip Code:76114-0117
Mailing Address - Country:US
Mailing Address - Phone:817-624-1222
Mailing Address - Fax:817-624-1213
Practice Address - Street 1:1601 E LAMAR BLVD
Practice Address - Street 2:214
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4510
Practice Address - Country:US
Practice Address - Phone:817-522-1095
Practice Address - Fax:817-460-0286
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68512101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional