Healthcare Provider Details

I. General information

NPI: 1790260727
Provider Name (Legal Business Name): MOLLY GIANNOTTA MS, LMHC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 06/07/2020
Certification Date: 06/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4475 US 1 S STE 603
ST AUGUSTINE FL
32086-7282
US

IV. Provider business mailing address

4475 US 1 S STE 603
ST AUGUSTINE FL
32086-7282
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-6619
  • Fax:
Mailing address:
  • Phone: 904-429-6619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH16002
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: