Provider Demographics
NPI:1639599111
Name:MOTTER, MISTY LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:MOTTER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 SMALLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:ENON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:16120-1324
Mailing Address - Country:US
Mailing Address - Phone:724-971-6094
Mailing Address - Fax:724-946-6297
Practice Address - Street 1:319 S MARKET ST
Practice Address - Street 2:
Practice Address - City:NEW WILMINGTON
Practice Address - State:PA
Practice Address - Zip Code:16172-0002
Practice Address - Country:US
Practice Address - Phone:724-971-6094
Practice Address - Fax:724-946-6297
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0035592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer