Provider Demographics
NPI:1578763272
Name:NELSON, MOLLY K (DPT)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:336 SW CYBER DR
Practice Address - Street 2:SUITE 107
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1683
Practice Address - Country:US
Practice Address - Phone:541-382-5500
Practice Address - Fax:541-389-5669
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274421Medicaid
OR274421Medicaid