Provider Demographics
NPI:1962515387
Name:ALTOBELLO, MOLLIE L (MPT)
Entity type:Individual
Prefix:MRS
First Name:MOLLIE
Middle Name:L
Last Name:ALTOBELLO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:MOLLIE
Other - Middle Name:R
Other - Last Name:LEMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:4767 FRANKFORT HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:RIDGELEY
Mailing Address - State:WV
Mailing Address - Zip Code:26753
Mailing Address - Country:US
Mailing Address - Phone:304-290-1602
Mailing Address - Fax:
Practice Address - Street 1:4767 FRANKFORT HIGHWAY
Practice Address - Street 2:
Practice Address - City:RIDGELEY
Practice Address - State:WV
Practice Address - Zip Code:26753
Practice Address - Country:US
Practice Address - Phone:301-729-3485
Practice Address - Fax:301-729-0158
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21834225100000X
WV002465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1069951OtherWORKERS COMP