Provider Demographics
NPI:1538421045
Name:MOLTON, GINA MARIE (LPTA)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:MARIE
Last Name:MOLTON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 HARVEST AVE
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2334
Mailing Address - Country:US
Mailing Address - Phone:618-337-1283
Mailing Address - Fax:618-344-9356
Practice Address - Street 1:601 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CASEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62232-1306
Practice Address - Country:US
Practice Address - Phone:618-344-9355
Practice Address - Fax:618-344-9356
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004618225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant