Provider Demographics
NPI:1912596164
Name:MCKEE-BURNSIDE, MOLLIE V (LCSW)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:V
Last Name:MCKEE-BURNSIDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:V
Other - Last Name:MCKEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10727 OLSEN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ZULCH
Mailing Address - State:TX
Mailing Address - Zip Code:77872-6694
Mailing Address - Country:US
Mailing Address - Phone:512-785-2176
Mailing Address - Fax:
Practice Address - Street 1:207 ROCK PRAIRIE RD STE A
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8777
Practice Address - Country:US
Practice Address - Phone:979-229-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX563091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical