Healthcare Provider Details

I. General information

NPI: 1578886271
Provider Name (Legal Business Name): MOLLY KATHRYN CHIZUM MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 HOLIDAY PL
FRANKLIN IN
46131-2622
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 463-222-2010
  • Fax: 463-222-2011
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05008314A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: