Provider Demographics
NPI:1053777268
Name:WILDFEUER, MOLLY MAE (MA)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:MAE
Last Name:WILDFEUER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:MOLLY
Other - Middle Name:MAE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3150 PIO PICO DR STE 105
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1951
Mailing Address - Country:US
Mailing Address - Phone:657-333-6860
Mailing Address - Fax:
Practice Address - Street 1:3150 PIO PICO DR STE 210
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1951
Practice Address - Country:US
Practice Address - Phone:657-333-6860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALPCC5397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health