MEDICARE: MOLLY MCKENNA PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	0012317	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NON	OTHER		NONE

General Provider Information

NPI Number	:	1326519315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY MCKENNA PTA

Provider Business Mailing Address
First Line	:	30 S NEVADA AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-1802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3740 CRAGWOOD DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-4912
Country	:	US
Telephone Number	:	719-237-8855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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