Provider Demographics
NPI:1396502209
Name:FULTZ, MOLLY JEAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JEAN
Last Name:FULTZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:JEAN
Other - Last Name:PERSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:503 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-2706
Mailing Address - Country:US
Mailing Address - Phone:269-598-8080
Mailing Address - Fax:
Practice Address - Street 1:2000 E OAKLEY PARK RD STE 101-B
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48390-1500
Practice Address - Country:US
Practice Address - Phone:248-387-5200
Practice Address - Fax:248-430-4141
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist