Provider Demographics
NPI:1467690248
Name:MOLINA, ANISSA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ANISSA
Middle Name:
Last Name:MOLINA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MARSH AVE
Mailing Address - Street 2:
Mailing Address - City:SAYREVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08872-1343
Mailing Address - Country:US
Mailing Address - Phone:732-234-6313
Mailing Address - Fax:
Practice Address - Street 1:4300 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-6505
Practice Address - Country:US
Practice Address - Phone:718-984-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-01
Last Update Date:2009-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016879-1235Z00000X
NJ41YS00539000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist