Healthcare Provider Details

I. General information

NPI: 1568298834
Provider Name (Legal Business Name): MOLLY KATE RODEBAUGH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 W LANCASTER AVE
WAYNE PA
19087-3924
US

IV. Provider business mailing address

122 CAROUSEL CIR
NEW BRITAIN PA
18901-5031
US

V. Phone/Fax

Practice location:
  • Phone: 610-688-8807
  • Fax:
Mailing address:
  • Phone: 267-471-9572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT008504
License Number StatePA

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: