Healthcare Provider Details

I. General information

NPI: 1205967015
Provider Name (Legal Business Name): MOLLY KENNEDY TRAYNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 4TH ST W
DICKINSON ND
58601-4951
US

IV. Provider business mailing address

7960 50TH ST SW
RICHARDTON ND
58652-9401
US

V. Phone/Fax

Practice location:
  • Phone: 701-456-0002
  • Fax: 701-456-0035
Mailing address:
  • Phone: 701-974-4218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number650
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: