=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093121451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY BEAR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2014
-----------------------------------------------------
Last Update Date | 07/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5535 S WILLIAMSON BLVD STE 774
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32128-8311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-330-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 470 E DEER VIEW DR
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17922-9077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OC012937
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------