Provider Demographics
NPI:1043319726
Name:BURTON, MOLLY HERZAN (PT)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:HERZAN
Last Name:BURTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ROSE
Other - Last Name:HERZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-3146
Mailing Address - Fax:
Practice Address - Street 1:4621 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-2338
Practice Address - Country:US
Practice Address - Phone:218-786-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7360225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043319726Medicaid