Provider Demographics
NPI:1720270705
Name:MOLLOY, ANDREA MICHELLE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MICHELLE
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:COON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4103 BRIDGEPORT WAY W.
Mailing Address - Street 2:STE C
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466
Mailing Address - Country:US
Mailing Address - Phone:253-460-1824
Mailing Address - Fax:253-460-1920
Practice Address - Street 1:4103 BRIDGEPORT WAY W.
Practice Address - Street 2:STE C
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466
Practice Address - Country:US
Practice Address - Phone:253-460-1824
Practice Address - Fax:253-460-1920
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022591225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist