Provider Demographics
NPI:1689090268
Name:MODICA, MOLLY ELIZABETH (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:MODICA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3747
Mailing Address - Country:US
Mailing Address - Phone:484-450-6476
Mailing Address - Fax:610-544-7142
Practice Address - Street 1:475 LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3747
Practice Address - Country:US
Practice Address - Phone:484-450-6476
Practice Address - Fax:610-544-7142
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
PAMF000772106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102918632Medicaid