Provider Demographics
NPI:1164568424
Name:MINNICK, MOLLY A (LMSW)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:MINNICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1617
Mailing Address - Country:US
Mailing Address - Phone:989-463-4971
Mailing Address - Fax:
Practice Address - Street 1:608 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1617
Practice Address - Country:US
Practice Address - Phone:989-463-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010570801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI80-0-89-2564-0OtherBCBSM
MI0M68980-03Medicare ID - Type UnspecifiedMEDICARE