Provider Demographics
NPI:1629736913
Name:MANNIX, MOLY MALONE
Entity Type:Individual
Prefix:
First Name:MOLY
Middle Name:MALONE
Last Name:MANNIX
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 1:53 SOUTHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3156
Mailing Address - Country:US
Mailing Address - Phone:860-573-6797
Mailing Address - Fax:
Practice Address - Street 1:53 SOUTHWOOD RD
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3156
Practice Address - Country:US
Practice Address - Phone:860-573-6797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical