MEDICARE: MOLI PEDIATRIC THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1053881904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOLI PEDIATRIC THERAPY, LLC

Provider Business Mailing Address
First Line	:	2008 GENERAL BOOTH BLVD STE B
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5910
Country	:	US
Telephone Number	:	757-803-5663
Fax Number	:	888-966-0621

Provider Business Practice Location Address
First Line	:	2008 GENERAL BOOTH BLVD STE B
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5910
Country	:	US
Telephone Number	:	757-301-2411
Fax Number	:	888-966-0621

Authorized Official
Title or Position	:	FOUNDER & CEO
Name	:	DANIELLE JACKSON LIPPOLDT
Credential	:	M.A.
Telephone Number	:	757-301-2411

Provider Enumeration Date	:	12/04/2018
Last Update Date	:	10/07/2022

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