Provider Demographics
NPI:1225278351
Name:BROWN, MOLLY SUZANNE
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:SUZANNE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:SUZANNE
Other - Last Name:BROWN-KOELLLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:3446 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2407
Mailing Address - Country:US
Mailing Address - Phone:503-901-8923
Mailing Address - Fax:
Practice Address - Street 1:2625 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2941
Practice Address - Country:US
Practice Address - Phone:503-238-9788
Practice Address - Fax:503-233-9163
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3630225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist