Provider Demographics
NPI:1275990723
Name:BURROUGHS, MOLLY ANN (MED)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 MAIN ST
Mailing Address - Street 2:#3
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4942
Mailing Address - Country:US
Mailing Address - Phone:630-945-0046
Mailing Address - Fax:
Practice Address - Street 1:918 MAIN ST
Practice Address - Street 2:#3
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-4942
Practice Address - Country:US
Practice Address - Phone:630-945-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist