Provider Demographics
NPI:1003854027
Name:MOLLOY, THERESE B (OT/L)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:B
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 WILTON CT NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-1448
Mailing Address - Country:US
Mailing Address - Phone:319-373-9674
Mailing Address - Fax:319-373-3197
Practice Address - Street 1:720 S DUBUQUE ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4249
Practice Address - Country:US
Practice Address - Phone:319-270-8492
Practice Address - Fax:319-373-3197
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00745225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00745OtherIOWA OT LICENSE
IAI19704Medicare PIN
IA00745OtherIOWA OT LICENSE