Provider Demographics
NPI:1174010433
Name:MOLLOY, ANISSA M (BCBA)
Entity type:Individual
Prefix:
First Name:ANISSA
Middle Name:M
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16860 EASTHAMPSTEAD RD APT 102
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-7832
Mailing Address - Country:US
Mailing Address - Phone:786-234-1740
Mailing Address - Fax:
Practice Address - Street 1:120 E BELLE ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4502
Practice Address - Country:US
Practice Address - Phone:252-272-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-21
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-90652106S00000X
FL1-24-72267103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician