Provider Demographics
NPI:1760083315
Name:MOLINA, STEPHANIE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARIE
Last Name:MOLINA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:STEPHANY
Other - Middle Name:M
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:96 SW ALLAPATTAH RD
Mailing Address - Street 2:
Mailing Address - City:INDIANTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:34956-4307
Mailing Address - Country:US
Mailing Address - Phone:772-597-9400
Mailing Address - Fax:
Practice Address - Street 1:96 SW ALLAPATTAH RD
Practice Address - Street 2:
Practice Address - City:INDIANTOWN
Practice Address - State:FL
Practice Address - Zip Code:34956-4307
Practice Address - Country:US
Practice Address - Phone:772-597-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11155103TC0700X
103TF0200X
MA11386103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic