Healthcare Provider Details

I. General information

NPI: 1891980363
Provider Name (Legal Business Name): MOLLIE MUNC PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MOLLIE HECKEL-MUNC PSYD

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 COLLEGE AVE STE A
SANTA ROSA CA
95404-3977
US

IV. Provider business mailing address

1212 COLLEGE AVE STE A
SANTA ROSA CA
95404-3977
US

V. Phone/Fax

Practice location:
  • Phone: 707-210-5350
  • Fax:
Mailing address:
  • Phone: 707-210-5350
  • Fax: 707-843-5095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: