Healthcare Provider Details

I. General information

NPI: 1003133414
Provider Name (Legal Business Name): MOLLI MCILVAINE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2010
Last Update Date: 04/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 GLENDALE BLVD SUITE 300B
LOS ANGELES CA
90039-1832
US

IV. Provider business mailing address

3807 ALOHA ST
LOS ANGELES CA
90027-3303
US

V. Phone/Fax

Practice location:
  • Phone: 323-863-6859
  • Fax:
Mailing address:
  • Phone: 323-863-6859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 48198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: