=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770259160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY RAFFERTY CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2021
-----------------------------------------------------
Last Update Date | 08/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6401 MARTINS MILL RD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19111-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-697-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 KAILA CT
-----------------------------------------------------
City | MEDIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19063-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-500-3093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------