Provider Demographics
NPI:1518015189
Name:MOLLISON, KAREN KELLY (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:KELLY
Last Name:MOLLISON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:VIA
Other - Last Name:MOLLISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:4602 E SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6115
Mailing Address - Country:US
Mailing Address - Phone:602-527-4829
Mailing Address - Fax:480-483-1026
Practice Address - Street 1:5040 E SHEA BLVD STE 168
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4686
Practice Address - Country:US
Practice Address - Phone:480-483-1025
Practice Address - Fax:480-483-1026
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0584235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ801474Medicaid