Basic Information
| Provider Information | |||||||||
| NPI: | 1619128014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAU | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | JOSSLYN | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 ROSEVILLE PKWY | ||||||||
| Address2: | APT. 314 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956784100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167709375 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 PRISON RD | ||||||||
| Address2: | |||||||||
| City: | REPRESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956713001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169852561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34003597A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.