Healthcare Provider Details

I. General information

NPI: 1275214090
Provider Name (Legal Business Name): MOLLIE DILLINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRONZE POINTE BLVD STE 2A
SWANSEA IL
62226-1045
US

IV. Provider business mailing address

1 BRONZE POINTE BLVD STE 2A
SWANSEA IL
62226-1045
US

V. Phone/Fax

Practice location:
  • Phone: 833-587-1784
  • Fax: 954-756-9593
Mailing address:
  • Phone: 833-587-1784
  • Fax: 954-756-9593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: