Provider Demographics
NPI:1801380936
Name:BLACK, MOLLY A (LSW)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:BLACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-1312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5665 HOOVER RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123
Practice Address - Country:US
Practice Address - Phone:614-875-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802284171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator