Provider Demographics
NPI:1295249589
Name:WHITELAW, MOLLIE (MA LLP)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:WHITELAW
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 VINSETTA BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1073
Mailing Address - Country:US
Mailing Address - Phone:248-470-3167
Mailing Address - Fax:
Practice Address - Street 1:43155 MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1777
Practice Address - Country:US
Practice Address - Phone:734-386-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007713103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist