Basic Information
| Provider Information | |||||||||
| NPI: | 1023509650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOERMAN | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | MAXINE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2446 E DODGE RD | ||||||||
| Address2: | |||||||||
| City: | CLIO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484209748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108537096 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1102 MACKIN RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485031204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2018 | ||||||||
| LastUpdateDate: | 05/18/2018 | ||||||||
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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 | 104100000X | 6802089156 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1043554348 | 05 | MI | MEDICAID |