Provider Demographics
NPI:1124117544
Name:MOLL, DAVID HOLTAN (MS, LP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:HOLTAN
Last Name:MOLL
Suffix:
Gender:M
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4704
Practice Address - Country:US
Practice Address - Phone:507-451-2630
Practice Address - Fax:507-455-8133
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4859103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN793323100Medicaid
MN62-20365OtherUNITED BEHAVIORAL HEALTH
MNHP27427OtherHEALTH PARTNERS
MN126989OtherUCARE
MN15G19MOOtherBLUE CROSS BLUE SHIELD