=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437229549
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLIE DAVIS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 10/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 MISSISSIPPI ST S
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-3025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-208-8499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 324 SFC 365
-----------------------------------------------------
City | COLT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72326-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-270-1388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A0308077
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | P0808062
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------