Provider Demographics
NPI:1295371599
Name:DYER, MOLLY (MS, MSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:DYER
Suffix:
Gender:F
Credentials:MS, MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4644
Mailing Address - Country:US
Mailing Address - Phone:217-258-2530
Mailing Address - Fax:217-258-4176
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4644
Practice Address - Country:US
Practice Address - Phone:217-258-2530
Practice Address - Fax:217-258-4176
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056013017225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056013017OtherLICENSE