Provider Demographics
NPI:1770223810
Name:MOLINA, MERIELLE
Entity Type:Individual
Prefix:
First Name:MERIELLE
Middle Name:
Last Name:MOLINA
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 1:467 LAKE HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5922
Mailing Address - Country:US
Mailing Address - Phone:407-449-2813
Mailing Address - Fax:
Practice Address - Street 1:325 TUDOR SPRING CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-6942
Practice Address - Country:US
Practice Address - Phone:305-537-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB774275106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107950700Medicaid