Provider Demographics
NPI:1396960530
Name:ITA, MOLLY ANN (SLP)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:ITA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25252 ROSELAWN RD
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-3701
Mailing Address - Country:US
Mailing Address - Phone:405-485-3347
Mailing Address - Fax:
Practice Address - Street 1:25252 ROSELAWN RD
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-3701
Practice Address - Country:US
Practice Address - Phone:405-485-3347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100173235Z00000X
CA15530235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist