Provider Demographics
NPI:1417213364
Name:BOETTCHER, MOLLY GRETCHEN (LMP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:GRETCHEN
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MELROSE AVE E APT 201
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-4744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 MELROSE AVE E APT 201
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-4744
Practice Address - Country:US
Practice Address - Phone:206-499-4314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60270983174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1268482OtherAMTA
WAMA60270983OtherWASHINGTON STATE LICENSE
WA611984-11OtherNCBTMB