Healthcare Provider Details

I. General information

NPI: 1164913331
Provider Name (Legal Business Name): MOLLY SICARD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STADIUM DR UNIVERSITY OF COLORADO
BOULDER CO
80309-0001
US

IV. Provider business mailing address

380 PALM LAKES BLVD
LITTLE RIVER SC
29566-7758
US

V. Phone/Fax

Practice location:
  • Phone: 303-492-3801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: