Provider Demographics
NPI:1053954362
Name:MOLLICA, JODI (LCSW)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:MOLLICA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010916871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty