Basic Information
| Provider Information | |||||||||
| NPI: | 1912170234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLLA | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1373 | ||||||||
| Address2: | |||||||||
| City: | CANYON COUNTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913861373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617765449 | ||||||||
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| Practice Location | |||||||||
| Address1: | 921 W AVENUE J | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612658627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 11/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | 56702 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MFC52671 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.