Provider Demographics
NPI:1740838184
Name:MICHALIK, MOLLY ROSE
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ROSE
Last Name:MICHALIK
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 1:100 S CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:PA
Mailing Address - Zip Code:17976-2112
Mailing Address - Country:US
Mailing Address - Phone:570-590-8278
Mailing Address - Fax:
Practice Address - Street 1:133 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0800
Practice Address - Country:US
Practice Address - Phone:570-208-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
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