Provider Demographics
NPI:1275044208
Name:BUELOW, MOLLIE
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:BUELOW
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 1:2600 COMPASS RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8001
Mailing Address - Country:US
Mailing Address - Phone:877-787-3430
Mailing Address - Fax:847-441-0734
Practice Address - Street 1:2929 S WATERFORD DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-4400
Practice Address - Country:US
Practice Address - Phone:509-960-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60822643224Z00000X
MT5319224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOC60822643OtherOTA LICENSE