Provider Demographics
NPI:1134332190
Name:MOLL, MARY H (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:MOLL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W. LAKE ST.
Mailing Address - Street 2:P.O. BOX 40
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934
Mailing Address - Country:US
Mailing Address - Phone:608-339-3331
Mailing Address - Fax:
Practice Address - Street 1:402 W. LAKE ST.
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934
Practice Address - Country:US
Practice Address - Phone:608-339-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40029400Medicaid