Healthcare Provider Details

I. General information

NPI: 1679218424
Provider Name (Legal Business Name): MOLLIE ELIZABETH KIDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MOLLIE ELIZABETH KISER

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4473 220TH AVE
REED CITY MI
49677-8593
US

IV. Provider business mailing address

854 S MCCLELLAND RD
WHITE CLOUD MI
49349-9733
US

V. Phone/Fax

Practice location:
  • Phone: 989-772-5930
  • Fax:
Mailing address:
  • Phone: 248-880-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: