Provider Demographics
NPI:1629573647
Name:MOLL, HEATHER (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:MOLL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 MORSON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-3960
Mailing Address - Country:US
Mailing Address - Phone:704-491-5877
Mailing Address - Fax:
Practice Address - Street 1:1351 ROBINWOOD RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1693
Practice Address - Country:US
Practice Address - Phone:704-867-2319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11655224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant