Provider Demographics
NPI:1063103364
Name:FEDEWA, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FEDEWA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13906 E KATHLEEN LN
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-9325
Mailing Address - Country:US
Mailing Address - Phone:517-643-5827
Mailing Address - Fax:
Practice Address - Street 1:4285 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4213
Practice Address - Country:US
Practice Address - Phone:517-706-0421
Practice Address - Fax:517-706-0423
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201014124225X00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician