Basic Information
| Provider Information | |||||||||
| NPI: | 1235404351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | IRENE | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1048 32ND ST SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495092806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162936876 | ||||||||
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| Practice Location | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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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 | 6801086154 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1715928 | 05 | MI | MEDICAID |