Provider Demographics
NPI:1477705531
Name:MOLINA, LYDIA (LISAC)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:
Last Name:MOLINA
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 E THOMAS RD STE 108
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3104
Mailing Address - Country:US
Mailing Address - Phone:602-235-9237
Mailing Address - Fax:602-222-6602
Practice Address - Street 1:49 E THOMAS RD STE 108
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3104
Practice Address - Country:US
Practice Address - Phone:602-235-9237
Practice Address - Fax:602-222-6602
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2630101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)