Provider Demographics
NPI:1174757884
Name:O'BRIEN, MOLLY A (LMT)
Entity type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:A
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:MOLLY
Other - Middle Name:A
Other - Last Name:MEDLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:415 N PASEO DE ONATE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2619
Mailing Address - Country:US
Mailing Address - Phone:505-753-3369
Mailing Address - Fax:505-753-4006
Practice Address - Street 1:1505 LLANO ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2004
Practice Address - Country:US
Practice Address - Phone:505-984-3034
Practice Address - Fax:505-984-3043
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5448225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist