Provider Demographics
NPI:1275214090
Name:DILLINGHAM, MOLLIE
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:DILLINGHAM
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 1:1 BRONZE POINTE BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1045
Mailing Address - Country:US
Mailing Address - Phone:833-587-1784
Mailing Address - Fax:954-756-9593
Practice Address - Street 1:1 BRONZE POINTE BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1045
Practice Address - Country:US
Practice Address - Phone:833-587-1784
Practice Address - Fax:954-756-9593
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician