Provider Demographics
NPI:1033546668
Name:MACIAS, MOLLIE THERESA
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:THERESA
Last Name:MACIAS
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 1:285 SOUTH ST STE J
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5037
Mailing Address - Country:US
Mailing Address - Phone:805-547-7025
Mailing Address - Fax:
Practice Address - Street 1:285 SOUTH ST STE J
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5037
Practice Address - Country:US
Practice Address - Phone:805-547-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health