Provider Demographics
NPI:1063061679
Name:MALCOLM, ALLURA
Entity type:Individual
Prefix:
First Name:ALLURA
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 N MELITA RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:MI
Mailing Address - Zip Code:48659-9766
Mailing Address - Country:US
Mailing Address - Phone:989-942-6157
Mailing Address - Fax:
Practice Address - Street 1:3005 BOARDWALK ST STE 201
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5218
Practice Address - Country:US
Practice Address - Phone:734-222-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017966103T00000X
MI6301019210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist