Provider Demographics
NPI:1528083953
Name:MALCOLM, THOMAS JONATHAN (PHD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JONATHAN
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W BENNETT AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-2568
Mailing Address - Country:US
Mailing Address - Phone:626-335-2466
Mailing Address - Fax:626-335-9686
Practice Address - Street 1:112 W BENNETT AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-2568
Practice Address - Country:US
Practice Address - Phone:626-335-2466
Practice Address - Fax:626-335-9686
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4156103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL41560Medicaid
CACP4156Medicare ID - Type Unspecified
CA00PL41560Medicaid