Provider Demographics
NPI:1053786525
Name:MOLLICA, STEPHANIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:MOLLICA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BRAMHALL STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:207-662-2847
Mailing Address - Fax:207-662-6434
Practice Address - Street 1:22 BRAMHALL STRRET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-2847
Practice Address - Fax:207-662-6434
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC21391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical