Provider Demographics
NPI:1902145121
Name:MOLDER, GENEVA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:GENEVA
Middle Name:
Last Name:MOLDER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 SEQUOIA PARK DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-5824
Mailing Address - Country:US
Mailing Address - Phone:405-354-4219
Mailing Address - Fax:
Practice Address - Street 1:5725 S ROSS AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-5650
Practice Address - Country:US
Practice Address - Phone:405-686-1972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK169224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant