Provider Demographics
NPI:1447432109
Name:MOLLEY, AMY (OT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MOLLEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 WAVELAND DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4222
Mailing Address - Country:US
Mailing Address - Phone:678-895-5223
Mailing Address - Fax:678-550-7684
Practice Address - Street 1:6478 PUTNAM FORD DR STE 124
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6987
Practice Address - Country:US
Practice Address - Phone:678-895-5223
Practice Address - Fax:678-550-7684
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004351225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004351OtherOCCUPATIONAL THERAPY
GA250330978GMedicaid