Provider Demographics
NPI:1538787874
Name:BURRETS, MOLLY (PHD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BURRETS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4628 TWINING ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-2035
Mailing Address - Country:US
Mailing Address - Phone:716-310-3562
Mailing Address - Fax:
Practice Address - Street 1:5619 N FIGUEROA ST APT 219
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4979
Practice Address - Country:US
Practice Address - Phone:716-310-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31378103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical