Provider Demographics
NPI:1124559638
Name:MARTIN, MOLLIE MAE
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:MAE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 RIVER REACH DR
Mailing Address - Street 2:APT 15
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-5815
Mailing Address - Country:US
Mailing Address - Phone:321-537-3110
Mailing Address - Fax:
Practice Address - Street 1:3201 BUDINGER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-7203
Practice Address - Country:US
Practice Address - Phone:407-910-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant