Provider Demographics
NPI:1720609464
Name:FENNER, MOLLY RENEA (CDCA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:RENEA
Last Name:FENNER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2441
Mailing Address - Country:US
Mailing Address - Phone:937-509-5773
Mailing Address - Fax:
Practice Address - Street 1:536 MILL ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2322
Practice Address - Country:US
Practice Address - Phone:740-773-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172637101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)