Provider Demographics
NPI:1992411201
Name:MOLINA, MYRTA IVIS
Entity type:Individual
Prefix:MRS
First Name:MYRTA
Middle Name:IVIS
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 1:18717 CALYPSO PL
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-1552
Mailing Address - Country:US
Mailing Address - Phone:301-300-9278
Mailing Address - Fax:
Practice Address - Street 1:610 E DIAMOND AVE STE 100A
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-5321
Practice Address - Country:US
Practice Address - Phone:301-300-9278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10535101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional