Provider Demographics
NPI:1083443295
Name:MALICDEM, CHELSEA MAY
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:MAY
Last Name:MALICDEM
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 1:6718 GARBER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3817
Mailing Address - Country:US
Mailing Address - Phone:619-200-1380
Mailing Address - Fax:
Practice Address - Street 1:9685 VIA EXCELENCIA STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-7500
Practice Address - Country:US
Practice Address - Phone:619-369-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-353836106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician