Provider Demographics
NPI:1649428038
Name:MATHISON, MOLLY JO (PT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JO
Last Name:MATHISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1910 W 69TH ST
Mailing Address - Street 2:AVERA OUTPATIENT THERAPY CLINIC
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5612
Mailing Address - Country:US
Mailing Address - Phone:605-322-5285
Mailing Address - Fax:605-322-5287
Practice Address - Street 1:1910 W 69TH ST
Practice Address - Street 2:AVERA OUTPATIENT THERAPY CLINIC
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5612
Practice Address - Country:US
Practice Address - Phone:605-322-5285
Practice Address - Fax:605-322-5287
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD1240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1649428038OtherMN BCBS
1649428038OtherMN BCBS