Provider Demographics
NPI:1114561941
Name:JODI MOLLICA LCSW LLC
Entity type:Organization
Organization Name:JODI MOLLICA LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLLICA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:248-321-8684
Mailing Address - Street 1:1040 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3330
Mailing Address - Country:US
Mailing Address - Phone:248-321-8684
Mailing Address - Fax:
Practice Address - Street 1:628 E PARENT AVE STE 506
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3768
Practice Address - Country:US
Practice Address - Phone:248-321-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801091687OtherLICENSE