Provider Demographics
NPI:1154984094
Name:CAMPBELL, MOLLY ELAINE (COTA/L)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ELAINE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-4764
Mailing Address - Country:US
Mailing Address - Phone:570-279-6572
Mailing Address - Fax:
Practice Address - Street 1:620 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-4764
Practice Address - Country:US
Practice Address - Phone:570-279-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP008139224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant