Provider Demographics
NPI:1558629329
Name:TETTEH, MOLLY (LCSW)
Entity type:Individual
Prefix:MISS
First Name:MOLLY
Middle Name:
Last Name:TETTEH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:594 BROADWAY RM 907
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-3289
Mailing Address - Country:US
Mailing Address - Phone:917-905-9801
Mailing Address - Fax:
Practice Address - Street 1:594 BROADWAY RM 907
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3289
Practice Address - Country:US
Practice Address - Phone:917-905-9801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085223104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY085223OtherLICENSE