Provider Demographics
NPI:1841793189
Name:TREVATHAN, MOLLY ANN (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:ANN
Last Name:TREVATHAN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 N 40TH ST APT 11
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2365
Mailing Address - Country:US
Mailing Address - Phone:314-221-5903
Mailing Address - Fax:
Practice Address - Street 1:701 FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102
Practice Address - Country:US
Practice Address - Phone:402-280-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer