Provider Demographics
NPI:1912498957
Name:KOBLE, MOLLIE
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:KOBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3060 FRONTIER WAY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8909
Mailing Address - Country:US
Mailing Address - Phone:701-232-2340
Mailing Address - Fax:
Practice Address - Street 1:4501 COLEMAN ST STE 103
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0996
Practice Address - Country:US
Practice Address - Phone:701-751-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherOCCUPATIONAL THERAPIST