Provider Demographics
NPI:1003868340
Name:CRUZ, MOLLY JO (PT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JO
Last Name:CRUZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:JO
Other - Last Name:DALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11782 SW BARNES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5931
Mailing Address - Country:US
Mailing Address - Phone:503-906-4323
Mailing Address - Fax:503-906-6613
Practice Address - Street 1:11782 SW BARNES RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5931
Practice Address - Country:US
Practice Address - Phone:503-906-4323
Practice Address - Fax:503-906-6613
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPT3340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPT3340OtherOREGON LICENSE
ORR171152Medicare PIN
OR1003868340Medicare PIN