Healthcare Provider Details

I. General information

NPI: 1508577099
Provider Name (Legal Business Name): MOLLY KOTOCAVAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N 29TH ST
CAMP HILL PA
17011-2910
US

IV. Provider business mailing address

255 N 29TH ST
CAMP HILL PA
17011-2910
US

V. Phone/Fax

Practice location:
  • Phone: 302-690-6993
  • Fax:
Mailing address:
  • Phone: 302-690-6993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOC018909
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC018909
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: