Healthcare Provider Details

I. General information

NPI: 1790576940
Provider Name (Legal Business Name): MOLLY SANFORD LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4467 CASCADE RD SE STE 4480
GRAND RAPIDS MI
49546-3776
US

IV. Provider business mailing address

2109 KENTUCKY ST
MIDLAND MI
48642-5709
US

V. Phone/Fax

Practice location:
  • Phone: 616-481-3784
  • Fax:
Mailing address:
  • Phone: 989-513-9923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6851120000
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: