Provider Demographics
NPI:1356071435
Name:KIRK, MOLLY MAGDALENE
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:MAGDALENE
Last Name:KIRK
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 1:1715 FRIENDSHIP CIR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-6917
Mailing Address - Country:US
Mailing Address - Phone:770-240-0163
Mailing Address - Fax:770-240-0163
Practice Address - Street 1:108 N WINDSOR LN
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-0976
Practice Address - Country:US
Practice Address - Phone:770-880-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB789280106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician