Provider Demographics
NPI:1386621621
Name:BLACKMORE, MOLLY S (LMFT)
Entity type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:S
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:LMFT
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Other - First Name:
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Mailing Address - Street 1:8085 WAYZATA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1453
Mailing Address - Country:US
Mailing Address - Phone:651-769-6300
Mailing Address - Fax:651-769-6349
Practice Address - Street 1:8085 WAYZATA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1453
Practice Address - Country:US
Practice Address - Phone:651-769-6300
Practice Address - Fax:651-769-6349
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2009-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN1056106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN323684600Medicaid