Provider Demographics
NPI:1063838423
Name:COLLINS, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4763
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-4763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23079 CREST FOREST DRIVE
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325
Practice Address - Country:US
Practice Address - Phone:909-436-8461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
227800000X, 2278E0002X, 2278G0305X, 2278G1100X
CA300482278H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome Health
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
No2278E0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedEmergency Care
No2278G0305XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeriatric Care
No2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care