=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528519642
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY AGRAVIADOR PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2016
-----------------------------------------------------
Last Update Date | 10/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20996 REDWOOD RD
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-5918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-537-0207
-----------------------------------------------------
Fax | 510-537-5819
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20996 REDWOOD RD
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-5918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-537-0207
-----------------------------------------------------
Fax | 510-537-5819
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA48120
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------