Provider Demographics
NPI:1306260633
Name:MOLINO, HOLLY (BCBA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:MOLINO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 NAPA DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7681
Mailing Address - Country:US
Mailing Address - Phone:208-705-6758
Mailing Address - Fax:
Practice Address - Street 1:2222 TETON PLZ
Practice Address - Street 2:SUITE 2
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6485
Practice Address - Country:US
Practice Address - Phone:208-522-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1-07-3437103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst