Provider Demographics
NPI:1144775289
Name:ROE, MOLLY ANNE (DPT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANNE
Last Name:ROE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ANNE
Other - Last Name:RED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3455 HIGHWAY 81
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9138
Mailing Address - Country:US
Mailing Address - Phone:770-554-0665
Mailing Address - Fax:770-554-0685
Practice Address - Street 1:47 POSTAL PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2885
Practice Address - Country:US
Practice Address - Phone:770-252-5279
Practice Address - Fax:770-252-9940
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20265I0181Medicare Oscar/Certification