Provider Demographics
NPI:1083167407
Name:RAMA, MOLLIE SHANNON
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:SHANNON
Last Name:RAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13260 N 94TH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4242
Mailing Address - Country:US
Mailing Address - Phone:623-487-7763
Mailing Address - Fax:623-486-8276
Practice Address - Street 1:13260 N 94TH DR STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4242
Practice Address - Country:US
Practice Address - Phone:623-487-7763
Practice Address - Fax:623-486-8276
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7971T101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor