Provider Demographics
NPI:1467675587
Name:MOLL, DIANE K
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:MOLL
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:PO BOX 4944
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4944
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:1246 YELLOWSTONE AVE
Practice Address - Street 2:SUITE C-6
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4374
Practice Address - Country:US
Practice Address - Phone:208-234-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor