Provider Demographics
NPI:1750594065
Name:BROOKS, MOLLY MARIE (COTA)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:MARIE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:845 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:920-322-0447
Mailing Address - Fax:920-322-1362
Practice Address - Street 1:845 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 120
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-322-0447
Practice Address - Fax:920-322-1362
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1180027224Z00000X
WI1198-827224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40886600Medicaid