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General NPI Number Information
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NPI Number | 1124438387
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Entity Type | Individual
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Provider Name | DWAYNE EDWARD MOLLISON SR. M.ED, LPCA
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Gender | Male
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Dates
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Enumeration Date | 04/28/2014
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Last Update Date | 04/28/2014
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Provider Practice Location Address
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Address Line | 4000 N DIXIE HWY STE 6 SUITE 6
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-4650
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Country | US
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Telephone | 270-889-1665
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Fax |
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Provider Business Mailing Address
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Address Line | 4000 N DIXIE HWY STE 6 SUITE 6
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-4650
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Country | US
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Telephone | 270-889-1665
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1642
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License Number State | KY
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