Provider Demographics
NPI:1952722456
Name:MOLINA, MAUREEN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MOLINA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 W RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1465
Mailing Address - Country:US
Mailing Address - Phone:715-441-0751
Mailing Address - Fax:
Practice Address - Street 1:1445 N 4TH ST
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1063
Practice Address - Country:US
Practice Address - Phone:715-246-6991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3896-154235Z00000X
MN9161235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist