Provider Demographics
NPI:1699542084
Name:MOLZON, LACIE LYNNE
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:LYNNE
Last Name:MOLZON
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 1:40 KUPUOHI ST
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-2701
Mailing Address - Country:US
Mailing Address - Phone:808-446-4561
Mailing Address - Fax:
Practice Address - Street 1:40 KUPUOHI ST
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-2701
Practice Address - Country:US
Practice Address - Phone:808-446-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI232252641505106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician