Provider Demographics
NPI:1487634473
Name:STANLEY, MOLLY DANA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:DANA
Last Name:STANLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3919
Mailing Address - Country:US
Mailing Address - Phone:207-799-2099
Mailing Address - Fax:
Practice Address - Street 1:345 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3919
Practice Address - Country:US
Practice Address - Phone:207-799-2099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME11851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME11540840OtherCAQH
ME008414OtherANTHEM BLUE CROSS
ME010424754Medicaid
ME11540840OtherCAQH