Provider Demographics
NPI:1003868340
Name:CRUZ, MOLLY JO (PT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JO
Last Name:CRUZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:JO
Other - Last Name:DALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:862 SE OAK ST
Mailing Address - Street 2:2A
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4240
Mailing Address - Country:US
Mailing Address - Phone:503-844-6565
Mailing Address - Fax:503-844-4225
Practice Address - Street 1:862 SE OAK ST
Practice Address - Street 2:2A
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4240
Practice Address - Country:US
Practice Address - Phone:503-844-6565
Practice Address - Fax:503-844-4225
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134700Medicare PIN
ORR171152Medicare PIN
OR1003868340Medicare PIN