Provider Demographics
NPI:1730362450
Name:MOLLO, KIMBERLY S (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:MOLLO
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GERMANTOWN PIKE STE A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1800
Mailing Address - Country:US
Mailing Address - Phone:215-290-0817
Mailing Address - Fax:
Practice Address - Street 1:600 GERMANTOWN PIKE STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444
Practice Address - Country:US
Practice Address - Phone:215-290-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU1-0001454174400000X
NJ46TR00443400174400000X
225XM0800X
PAOC010410174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022381OtherNEW YORK LICENSE
NJ46TR00443400OtherOCCUPATIONAL THERAPY LICENSURE
DEU1-0001454OtherDELAWARE LICENSURE
PAOC010410OtherOCCUPATIONAL THERAPY LICENSURE