1649428038 NPI number — MOLLY JO MATHISON P.T.

Table of content: MOLLY JO MATHISON P.T. (NPI 1649428038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649428038 NPI number — MOLLY JO MATHISON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHISON
Provider First Name:
MOLLY
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649428038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 W 69TH ST
Provider Second Line Business Mailing Address:
AVERA OUTPATIENT THERAPY CLINIC
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57108-5612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-5285
Provider Business Mailing Address Fax Number:
605-322-5287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 W 69TH ST
Provider Second Line Business Practice Location Address:
AVERA OUTPATIENT THERAPY CLINIC
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108-5612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-5285
Provider Business Practice Location Address Fax Number:
605-322-5287
Provider Enumeration Date:
08/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1240 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1649428038 . This is a "MN BCBS" identifier . This identifiers is of the category "OTHER".




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