| Doctor Name: | MOLLY PORT |
| NPI Number: | 1124431101 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LAC |
| License Number: | LAC-14556 |
| Business Practice Address: | 1947 Mcculloch Blvd N Ste 103 Lake Havasu City, AZ - 864035723 |
| Business Phone Number: | 9284530404 |
| Business Fax Number: | |
| Mailing Address: | 1947 Mcculloch Blvd N Ste 103, LAKE HAVASU CITY |
| State: | AZ |
| Postal Code: | 864035723 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 06/06/2014 |
| NPI Last Update Date: | 06/06/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | LAC-14556 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |