Provider Demographics
NPI:1790251510
Name:GAINES, MOLLY MARGARET (MA)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:MARGARET
Last Name:GAINES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:MARGARET
Other - Last Name:BETTINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPH
Mailing Address - Street 1:15305 RAYEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5117
Mailing Address - Country:US
Mailing Address - Phone:818-892-3423
Mailing Address - Fax:818-893-4509
Practice Address - Street 1:15305 RAYEN ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5117
Practice Address - Country:US
Practice Address - Phone:818-892-3423
Practice Address - Fax:818-893-4509
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT122333106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL