Provider Demographics
NPI:1023547882
Name:DAVIS, MOLLY GRETCHEN (LPC, MAC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:GRETCHEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 W KATMAI AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7315
Mailing Address - Country:US
Mailing Address - Phone:907-741-1683
Mailing Address - Fax:
Practice Address - Street 1:198 W MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7501
Practice Address - Country:US
Practice Address - Phone:907-741-1683
Practice Address - Fax:907-741-1683
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK109623101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK109623OtherLICENSED PROFESSIONAL COUNSELOR