Provider Demographics
NPI:1629755798
Name:MMOLA, LYDIA BABY (CSW)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:BABY
Last Name:MMOLA
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 N MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-5009
Mailing Address - Country:US
Mailing Address - Phone:435-850-7378
Mailing Address - Fax:
Practice Address - Street 1:1244 N MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-5009
Practice Address - Country:US
Practice Address - Phone:435-850-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13457610-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker