Provider Demographics
NPI:1164472924
Name:DE MOLINA, MICHAEL W (MS, LPC, CDCS, MAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:DE MOLINA
Suffix:
Gender:M
Credentials:MS, LPC, CDCS, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W INTERNATIONAL AIRPORT RD STE 17
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-1168
Mailing Address - Country:US
Mailing Address - Phone:907-770-3656
Mailing Address - Fax:907-562-4503
Practice Address - Street 1:401 W INTERNATIONAL AIRPORT RD STE 17
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1168
Practice Address - Country:US
Practice Address - Phone:907-770-3656
Practice Address - Fax:907-562-4503
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK420101YP2500X, 101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH3681Medicaid