Provider Demographics
NPI:1841497377
Name:BLAIR, MOLLIE SULLIVAN (OTRL)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:SULLIVAN
Last Name:BLAIR
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MILES AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:LORETTO
Mailing Address - State:KY
Mailing Address - Zip Code:40037-8050
Mailing Address - Country:US
Mailing Address - Phone:270-865-3615
Mailing Address - Fax:
Practice Address - Street 1:420 E GRUNDY AVE
Practice Address - Street 2:SPRINGFIELD NSG AND REHAB CENTER
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069-1173
Practice Address - Country:US
Practice Address - Phone:859-336-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2901225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12500872Medicaid