Provider Demographics
NPI:1285187591
Name:MOLES, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:MOLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6157 N KENMORE APT #4S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660
Mailing Address - Country:US
Mailing Address - Phone:312-404-8401
Mailing Address - Fax:
Practice Address - Street 1:6157 N KENMORE
Practice Address - Street 2:APT #4S
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660
Practice Address - Country:US
Practice Address - Phone:312-404-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist