Provider Demographics
NPI:1588384770
Name:ISLES, MOLLY ROSE (CADAC II)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ROSE
Last Name:ISLES
Suffix:
Gender:F
Credentials:CADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 YUMA RD
Mailing Address - Street 2:
Mailing Address - City:WEST TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47885-9654
Mailing Address - Country:US
Mailing Address - Phone:765-505-3156
Mailing Address - Fax:
Practice Address - Street 1:500 FARRINGTON ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-5095
Practice Address - Country:US
Practice Address - Phone:812-917-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC2-51270101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC2-51270Medicaid