Provider Demographics
NPI:1053945881
Name:MOLINA, MASEMANTHA MONIQUE (PT)
Entity type:Individual
Prefix:
First Name:MASEMANTHA
Middle Name:MONIQUE
Last Name:MOLINA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-5790
Mailing Address - Country:US
Mailing Address - Phone:718-302-0456
Mailing Address - Fax:718-218-8878
Practice Address - Street 1:601 W 182ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3903
Practice Address - Country:US
Practice Address - Phone:718-302-0456
Practice Address - Fax:718-218-8878
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist