Provider Demographics
NPI:1740479336
Name:GIERASCH, MOLLY (PHD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:GIERASCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BROWNS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-7612
Mailing Address - Country:US
Mailing Address - Phone:575-534-2856
Mailing Address - Fax:
Practice Address - Street 1:1911 MAIN AVE
Practice Address - Street 2:STE 258
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5083
Practice Address - Country:US
Practice Address - Phone:575-534-2856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1916103T00000X
NM1113103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC63106Medicare PIN