Provider Demographics
NPI:1750689493
Name:LUSSIER, MOLLY M (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BEE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-5703
Mailing Address - Country:US
Mailing Address - Phone:843-789-6975
Mailing Address - Fax:843-572-8135
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-789-6975
Practice Address - Fax:843-572-8135
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4479363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC048Medicaid
SC421896Medicare Oscar/Certification
SC7124Medicare PIN
SC372048Medicaid