Basic Information
| Provider Information | |||||||||
| NPI: | 1528474301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LLMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARX | ||||||||
| OtherFirstName: | MOLLY | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, APSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3138312608 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3138312608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2014 | ||||||||
| LastUpdateDate: | 07/01/2014 | ||||||||
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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 | 101YA0400X | 16591-130 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 6801096024 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 129072-121 | WI | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.