1942271747 NPI number — MS. MALAYSIA HELENE GRESHAM LICSW

Table of content: MS. MALAYSIA HELENE GRESHAM LICSW (NPI 1942271747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942271747 NPI number — MS. MALAYSIA HELENE GRESHAM LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRESHAM
Provider First Name:
MALAYSIA
Provider Middle Name:
HELENE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942271747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 S 34TH ST
Provider Second Line Business Mailing Address:
APT 315
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-6045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-747-3190
Provider Business Mailing Address Fax Number:
701-747-7340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
1599 J STREET
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-747-3190
Provider Business Practice Location Address Fax Number:
701-747-7340
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  G10359 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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