Provider Demographics
NPI:1447615380
Name:PROUT, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:PROUT
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 1:464 CENTRAL AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3040
Mailing Address - Country:US
Mailing Address - Phone:224-216-2624
Mailing Address - Fax:
Practice Address - Street 1:464 CENTRAL AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3040
Practice Address - Country:US
Practice Address - Phone:224-216-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178010298101YP2500X
IL180010859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional