Provider Demographics
NPI:1821195850
Name:TICKNOR, MOLLY J (MA, ATR, LPC)
Entity Type:Individual
Prefix:MISS
First Name:MOLLY
Middle Name:J
Last Name:TICKNOR
Suffix:
Gender:F
Credentials:MA, ATR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18600 E 37TH TER S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1707
Mailing Address - Country:US
Mailing Address - Phone:816-659-9383
Mailing Address - Fax:
Practice Address - Street 1:18600 E 37TH TER S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1707
Practice Address - Country:US
Practice Address - Phone:816-659-9383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014995101YM0800X
MO2004014955101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499302701Medicaid