Provider Demographics
NPI:1699292961
Name:BRUCKER, MOLLY (PT, DPT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BRUCKER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:CORNELISSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 416495
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6495
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:80 MILL ST STE 1
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1411
Practice Address - Country:US
Practice Address - Phone:973-940-7311
Practice Address - Fax:973-940-7342
Is Sole Proprietor?:No
Enumeration Date:2017-08-27
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6280225100000X
NJ40QA01740300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist