Provider Demographics
NPI:1407905029
Name:MOLLOY, PATRICK BRYAN (LPC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:BRYAN
Last Name:MOLLOY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25945 SANDLEWOOD LN
Mailing Address - Street 2:PO BOX 175
Mailing Address - City:LAQUEY
Mailing Address - State:MO
Mailing Address - Zip Code:65534-7615
Mailing Address - Country:US
Mailing Address - Phone:573-528-7792
Mailing Address - Fax:573-774-6992
Practice Address - Street 1:1400 STATE ROAD F
Practice Address - Street 2:SUITE 102
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-0000
Practice Address - Country:US
Practice Address - Phone:573-528-7792
Practice Address - Fax:573-774-6992
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024725101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional