| Molly Port | |
|
1930 Mesquite Ave #1a Lake Havasu City AZ 86403 | |
| (928) 855-4900 | |
| (928) 855-4902 |
| Full Name | Molly Port |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 1930 Mesquite Ave, Lake Havasu City, Arizona |
| Authorized Official Name and Position | Molly Port (OWNER/LICENSED PROFESSIONAL COUNSEL) |
| Authorized Official Contact | 9288554900 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Molly Port 1930 Mesquite Ave #1a Lake Havasu City AZ 86403 Ph: (928) 855-4900 | Molly Port 1930 Mesquite Ave #1a Lake Havasu City AZ 86403 Ph: (928) 855-4900 |
| NPI Number | 1134668841 |
|---|---|
| Provider Enumeration Date | 02/14/2017 |
| Last Update Date | 04/27/2019 |
| Medicare PECOS PAC ID | 9335588268 |
|---|---|
| Medicare Enrollment ID | O20240411003174 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1134668841 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 16468 (Arizona) | Primary |
| Provider Name | Molly Port |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1124431101 PECOS PAC ID: 0244679173 Enrollment ID: I20240411003233 |
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