Provider Demographics
NPI:1083195812
Name:TAPIA-CRISANTO, AZUCENA MOLLY
Entity Type:Individual
Prefix:
First Name:AZUCENA
Middle Name:MOLLY
Last Name:TAPIA-CRISANTO
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 1:1016 KATHRYN RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2170
Mailing Address - Country:US
Mailing Address - Phone:240-441-6805
Mailing Address - Fax:
Practice Address - Street 1:10411 MOTOR CITY DR STE 750
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1289
Practice Address - Country:US
Practice Address - Phone:888-805-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA1114103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst