Healthcare Provider Details

I. General information

NPI: 1174757884
Provider Name (Legal Business Name): MOLLY A O'BRIEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MOLLY A MEDLIN LMT

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 05/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 LLANO ST STE A
SANTA FE NM
87505-2004
US

IV. Provider business mailing address

415 N PASEO DE ONATE
ESPANOLA NM
87532-2619
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-3034
  • Fax: 505-984-3043
Mailing address:
  • Phone: 505-753-3369
  • Fax: 505-753-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5448
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: