Provider Demographics
NPI:1174010433
Name:MOLLOY, ANISSA M
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:M
Last Name:MOLLOY
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 1:1321 MURFREESBORO PIKE STE 702
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-2679
Mailing Address - Country:US
Mailing Address - Phone:844-359-7629
Mailing Address - Fax:615-577-5654
Practice Address - Street 1:3217 S MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-1719
Practice Address - Country:US
Practice Address - Phone:132-847-9418
Practice Address - Fax:615-577-5654
Is Sole Proprietor?:No
Enumeration Date:2018-04-21
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-90652106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician