Provider Demographics
NPI:1376815308
Name:HARRISON, MOLLY JOAN (LEP, NCSP)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:JOAN
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LEP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15240 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-9434
Mailing Address - Country:US
Mailing Address - Phone:530-263-3206
Mailing Address - Fax:
Practice Address - Street 1:2330 PROFESSIONAL DR STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7781
Practice Address - Country:US
Practice Address - Phone:530-263-3206
Practice Address - Fax:916-786-5487
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3003103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool