=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376815308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY JOAN HARRISON LEP, NCSP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2012
-----------------------------------------------------
Last Update Date | 02/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2330 PROFESSIONAL DR STE 100
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-7781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-263-3206
-----------------------------------------------------
Fax | 916-786-5487
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15240 LEWIS RD
-----------------------------------------------------
City | NEVADA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95959-9434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-263-3206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 3003
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------