Provider Demographics
NPI:1043026081
Name:LEWIS, MOLLY (COTA/L)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:360 GALILEE RD
Mailing Address - Street 2:
Mailing Address - City:WOLF LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:62998-1011
Mailing Address - Country:US
Mailing Address - Phone:618-629-2060
Mailing Address - Fax:
Practice Address - Street 1:310 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ORAN
Practice Address - State:MO
Practice Address - Zip Code:63771-9602
Practice Address - Country:US
Practice Address - Phone:573-262-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021033962224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant