Provider Demographics
NPI:1821529223
Name:MCDONALD, MOLLY (LMT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MCDONALD
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 1:1441 S FENBROOK LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4176
Mailing Address - Country:US
Mailing Address - Phone:812-929-1978
Mailing Address - Fax:
Practice Address - Street 1:8937 SOUTHPOINTE DR
Practice Address - Street 2:STE A-1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1086
Practice Address - Country:US
Practice Address - Phone:317-851-8419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21003472225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist