Provider Demographics
NPI:1346950490
Name:TIEXIERA, MOLLY MICHELLE
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:MICHELLE
Last Name:TIEXIERA
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 1:514 W MAPLE ST STE 106
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2420
Mailing Address - Country:US
Mailing Address - Phone:770-740-5135
Mailing Address - Fax:
Practice Address - Street 1:514 W MAPLE ST STE 106
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2420
Practice Address - Country:US
Practice Address - Phone:770-740-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA070532330OtherLICENSE