Provider Demographics
NPI:1124431101
Name:PORT, MOLLY (LPC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:PORT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 MESQUITE AVE
Mailing Address - Street 2:SUITE # 1A
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:928-855-4900
Mailing Address - Fax:928-855-4902
Practice Address - Street 1:1930 MESQUITE AVE
Practice Address - Street 2:SUITE # 1A
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-855-4900
Practice Address - Fax:928-855-4902
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-16468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional