Provider Demographics
NPI:1609157023
Name:MOLDENHAUER, TAMMY (OT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:MOLDENHAUER
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 1:4301 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-3135
Mailing Address - Country:US
Mailing Address - Phone:940-781-1765
Mailing Address - Fax:817-977-5547
Practice Address - Street 1:409 SHORE LINE DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-5711
Practice Address - Country:US
Practice Address - Phone:940-781-1765
Practice Address - Fax:817-977-5547
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109583225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist