Provider Demographics
NPI:1487087284
Name:DUCKWORTH, MALISSA ELAINE (LCSW)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:ELAINE
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 WINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-2420
Mailing Address - Country:US
Mailing Address - Phone:901-268-2562
Mailing Address - Fax:
Practice Address - Street 1:711 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-5003
Practice Address - Country:US
Practice Address - Phone:901-448-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical