Provider Demographics
NPI:1528635588
Name:MOLINA, LEAH RAE
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:RAE
Last Name:MOLINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 E FORT UNION BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5531
Mailing Address - Country:US
Mailing Address - Phone:801-984-1717
Mailing Address - Fax:801-984-1717
Practice Address - Street 1:613 E FORT UNION BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-5531
Practice Address - Country:US
Practice Address - Phone:801-984-1717
Practice Address - Fax:801-984-1717
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13403007-35011041C0700X
1041C0700X
AZD09262745390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program