Provider Demographics
NPI:1023762325
Name:WILSON, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:WILSON
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 1:2740 COUNTY ROAD 135
Mailing Address - Street 2:
Mailing Address - City:DOLA
Mailing Address - State:OH
Mailing Address - Zip Code:45835-9735
Mailing Address - Country:US
Mailing Address - Phone:567-674-2031
Mailing Address - Fax:
Practice Address - Street 1:474 LAUKAPU ST STE 2
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4414
Practice Address - Country:US
Practice Address - Phone:808-339-7478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH439046225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist