Provider Demographics
NPI:1396106803
Name:STREET, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:STREET
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:N4422 COUNTY ROAD P
Mailing Address - Street 2:
Mailing Address - City:HELENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53137-9765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N4422 COUNTY ROAD P
Practice Address - Street 2:
Practice Address - City:HELENVILLE
Practice Address - State:WI
Practice Address - Zip Code:53137-9765
Practice Address - Country:US
Practice Address - Phone:920-342-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer