Provider Demographics
NPI:1386042331
Name:BROCKWAY, MOLLY (LMSW)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:STRATTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-1525
Mailing Address - Country:US
Mailing Address - Phone:802-688-9518
Mailing Address - Fax:
Practice Address - Street 1:52 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-3055
Practice Address - Country:US
Practice Address - Phone:603-542-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
RE2534Medicare PIN