Provider Demographics
NPI:1295003341
Name:MOLOCZNIK, MARIANN THERESA (OTRL)
Entity Type:Individual
Prefix:MISS
First Name:MARIANN
Middle Name:THERESA
Last Name:MOLOCZNIK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 EAGLE TRACE
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1508
Mailing Address - Country:US
Mailing Address - Phone:518-877-8142
Mailing Address - Fax:
Practice Address - Street 1:10 EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033
Practice Address - Country:US
Practice Address - Phone:518-477-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0029591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist