Provider Demographics
NPI:1023794575
Name:MCQUILLAN, MOLLY M
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:MCQUILLAN
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 1:40722 OH-154
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-0381
Mailing Address - Country:US
Mailing Address - Phone:330-424-9573
Mailing Address - Fax:
Practice Address - Street 1:40722 OH-154
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432
Practice Address - Country:US
Practice Address - Phone:330-424-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid