Healthcare Provider Details

I. General information

NPI: 1053881904
Provider Name (Legal Business Name): MOLI PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 GENERAL BOOTH BLVD STE B
VIRGINIA BEACH VA
23454-5910
US

IV. Provider business mailing address

2008 GENERAL BOOTH BLVD STE B
VIRGINIA BEACH VA
23454-5910
US

V. Phone/Fax

Practice location:
  • Phone: 757-301-2411
  • Fax: 888-966-0621
Mailing address:
  • Phone: 757-803-5663
  • Fax: 888-966-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE JACKSON LIPPOLDT
Title or Position: FOUNDER & CEO
Credential: M.A.
Phone: 757-301-2411