Basic Information
| Provider Information | |||||||||
| NPI: | 1215339288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARCHER | ||||||||
| FirstName: | MOLLIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 TECHNACENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361176028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346255795 | ||||||||
| FaxNumber: | 3343964905 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 IVEY RD NW | ||||||||
| Address2: | BUILDING 1000 SUITE 1001 | ||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301014001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709170924 | ||||||||
| FaxNumber: | 7709170926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2014 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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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 | PT011667 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 13670204 | 01 | GA | CAQH | OTHER |