Provider Demographics
NPI:1326715970
Name:HAYWORTH, MOLLY BROOKE (PTA)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:BROOKE
Last Name:HAYWORTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5391 THORNAPPLE LN APT 201
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-3463
Mailing Address - Country:US
Mailing Address - Phone:815-347-6883
Mailing Address - Fax:
Practice Address - Street 1:5391 THORNAPPLE LN APT 201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-3463
Practice Address - Country:US
Practice Address - Phone:815-347-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006341A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty