Provider Demographics
NPI:1699006767
Name:MOLINA, EMMANUEL SALVADOR BAUTISTA (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL SALVADOR
Middle Name:BAUTISTA
Last Name:MOLINA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:MR
Other - First Name:EMMANUEL SALVADOR
Other - Middle Name:BAUTISTA
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2320 N VERMILION ST
Mailing Address - Street 2:APARTMENT 217
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1739
Mailing Address - Country:US
Mailing Address - Phone:815-295-3529
Mailing Address - Fax:
Practice Address - Street 1:1265 S SEMORAN BLVD
Practice Address - Street 2:SUITE 1221
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-5527
Practice Address - Country:US
Practice Address - Phone:407-681-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008165225X00000X
IN31005053A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist