Provider Demographics
NPI:1548790082
Name:PROFFER, MOLLY ANNA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANNA
Last Name:PROFFER
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3120 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5043
Practice Address - Country:US
Practice Address - Phone:573-240-8846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014031451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist