Provider Demographics
NPI:1790434454
Name:EGEBERG, MOLLY M (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:M
Last Name:EGEBERG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-3506
Mailing Address - Country:US
Mailing Address - Phone:515-720-0942
Mailing Address - Fax:
Practice Address - Street 1:407 W BRIDGE RD STE 8
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:IA
Practice Address - Zip Code:50226-2310
Practice Address - Country:US
Practice Address - Phone:515-984-6484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA092005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist