Provider Demographics
NPI:1396700548
Name:PRINCE, MOLLY GEORGE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:GEORGE
Last Name:PRINCE
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:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-0179
Mailing Address - Country:US
Mailing Address - Phone:801-680-4705
Mailing Address - Fax:801-906-0129
Practice Address - Street 1:3098 S HIGHLAND DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3085
Practice Address - Country:US
Practice Address - Phone:801-680-4705
Practice Address - Fax:801-906-0129
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT333285-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT03332853501001OtherBCBS
UT000064813Medicare PIN