Provider Demographics
NPI:1205942679
Name:MOLLEN, EILEEN (PHD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:MOLLEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 WASHTENAW AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4500
Mailing Address - Country:US
Mailing Address - Phone:734-995-5181
Mailing Address - Fax:734-995-9011
Practice Address - Street 1:2300 WASHTENAW AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4500
Practice Address - Country:US
Practice Address - Phone:734-995-5181
Practice Address - Fax:734-995-9011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007391103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP04255Medicare UPIN