Provider Demographics
NPI:1659487957
Name:THOMA, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:THOMA
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 1:350 PAGELOW RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:WI
Mailing Address - Zip Code:53521-9426
Mailing Address - Country:US
Mailing Address - Phone:608-455-6026
Mailing Address - Fax:
Practice Address - Street 1:1130 COLLINS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-2939
Practice Address - Country:US
Practice Address - Phone:920-674-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2432-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist