Provider Demographics
NPI:1205870128
Name:MANUEL, MOLLY ELLEN (DPT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ELLEN
Last Name:MANUEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ELLEN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2234 W HOUSTON ST STE B
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3519
Mailing Address - Country:US
Mailing Address - Phone:918-259-1888
Mailing Address - Fax:918-251-3725
Practice Address - Street 1:1742 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-5901
Practice Address - Country:US
Practice Address - Phone:405-825-3617
Practice Address - Fax:405-825-3618
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200533540AMedicaid
OK352166ZTQLMedicare PIN