Provider Demographics
NPI:1609297407
Name:MCKEOWN, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MCKEOWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 YORK ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-3927
Mailing Address - Country:US
Mailing Address - Phone:716-378-1423
Mailing Address - Fax:
Practice Address - Street 1:6133 ROUTE 219 S
Practice Address - Street 2:
Practice Address - City:ELLICOTTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14731-9613
Practice Address - Country:US
Practice Address - Phone:716-699-2312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037293-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist