Provider Demographics
NPI:1124438387
Name:MOLLISON, DWAYNE EDWARD SR (MED, LPCA)
Entity type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:EDWARD
Last Name:MOLLISON
Suffix:SR
Gender:M
Credentials:MED, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 N DIXIE HWY STE 6
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-4650
Mailing Address - Country:US
Mailing Address - Phone:270-889-1665
Mailing Address - Fax:
Practice Address - Street 1:4000 N DIXIE HWY STE 6
Practice Address - Street 2:SUITE 6
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-4650
Practice Address - Country:US
Practice Address - Phone:270-889-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1642101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health