Basic Information
| Provider Information | |||||||||
| NPI: | 1598857641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOLLY TRAFFAS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3425 W CENTRAL AVE. | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672034919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169460990 | ||||||||
| FaxNumber: | 3169431139 | ||||||||
| Practice Location | |||||||||
| Address1: | 3425 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672034919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169460990 | ||||||||
| FaxNumber: | 3169431139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | TRAFFAS | ||||||||
| AuthorizedOfficialFirstName: | MOLLY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3169460990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LSCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2240 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100457290B | 05 | KS | MEDICAID | 180517 | 01 | KS | BC/BS | OTHER |