Provider Demographics
NPI:1073619292
Name:MOLLOY, STEPHEN (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MOLLOY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 FOREST AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3359
Mailing Address - Country:US
Mailing Address - Phone:513-246-7800
Mailing Address - Fax:513-246-7852
Practice Address - Street 1:379 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:513-246-7590
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2484280Medicaid
OHMO4109992Medicare PIN