Basic Information
| Provider Information | |||||||||
| NPI: | 1245633767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALA | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7720 | ||||||||
| Address2: | CREDENTIALING SPECIALIST | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065190720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033174 | ||||||||
| FaxNumber: | 2035033183 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 MAIN STREET | ||||||||
| Address2: | WEST HAVEN HEALTH CENTER COUNSELING SERVICES | ||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065167307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033409 | ||||||||
| FaxNumber: | 2035033414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9535 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 004235918 | 05 | CT | MEDICAID |