Provider Demographics
NPI:1164555025
Name:TAVERNESE, MOLLY MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:MARIE
Last Name:TAVERNESE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:MARIE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10329 AQUILLA DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2213
Mailing Address - Country:US
Mailing Address - Phone:619-818-7470
Mailing Address - Fax:
Practice Address - Street 1:10329 AQUILLA DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-2213
Practice Address - Country:US
Practice Address - Phone:619-818-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT51663106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist