Provider Demographics
NPI:1881769842
Name:STUCHLIK, MOLLIE R (OTR)
Entity type:Individual
Prefix:MRS
First Name:MOLLIE
Middle Name:R
Last Name:STUCHLIK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:R
Other - Last Name:CRAMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:321 LOG AVENUE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050
Mailing Address - Country:US
Mailing Address - Phone:719-384-0381
Mailing Address - Fax:
Practice Address - Street 1:900 SOUTH 12TH STREET
Practice Address - Street 2:
Practice Address - City:ROCKY FORD
Practice Address - State:CO
Practice Address - Zip Code:81067
Practice Address - Country:US
Practice Address - Phone:719-254-4202
Practice Address - Fax:719-254-4202
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1007653225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72489731Medicaid