Provider Demographics
NPI:1275104770
Name:MOLL, ALYCIA G
Entity Type:Individual
Prefix:MRS
First Name:ALYCIA
Middle Name:G
Last Name:MOLL
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 1:628 LAKE ST NE
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-7919
Mailing Address - Country:US
Mailing Address - Phone:276-328-8017
Mailing Address - Fax:
Practice Address - Street 1:628 LAKE ST NE
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-7919
Practice Address - Country:US
Practice Address - Phone:276-328-8017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist