Provider Demographics
NPI:1306132345
Name:BASIC, MOLLIE (DPT)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:BASIC
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:
Other - Last Name:KIMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15127 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3708
Practice Address - Country:US
Practice Address - Phone:708-403-4497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00994444OtherMCRR
IL216859188Medicare PIN