Provider Demographics
NPI:1033860127
Name:REA, MOLLY GRACE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:GRACE
Last Name:REA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14109 SW ALESCA LN
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9114
Mailing Address - Country:US
Mailing Address - Phone:803-394-1352
Mailing Address - Fax:
Practice Address - Street 1:2303 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1655
Practice Address - Country:US
Practice Address - Phone:503-213-6970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26795225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist