Provider Demographics
NPI:1902320526
Name:WHITE, MOLLY M (DPT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:WHITE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:E
Other - Last Name:MAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-626-0160
Mailing Address - Fax:203-294-6734
Practice Address - Street 1:12 BOKUM RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1500
Practice Address - Country:US
Practice Address - Phone:860-767-9053
Practice Address - Fax:203-466-8527
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT$$$$$$$$$OtherPROVIDER SOCIAL SECURITY