Basic Information
| Provider Information | |||||||||
| NPI: | 1578017489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAXBERG | ||||||||
| FirstName: | MOLLYE | ||||||||
| MiddleName: | REBECCA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIPTON | ||||||||
| OtherFirstName: | MOLLYE | ||||||||
| OtherMiddleName: | REBECCA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10710 CHARTER DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210443128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106441880 | ||||||||
| FaxNumber: | 4107301617 | ||||||||
| Practice Location | |||||||||
| Address1: | 10710 CHARTER DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210443128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106441880 | ||||||||
| FaxNumber: | 4107301617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2016 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 26083 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.