MEDICARE: MOLLY RENEE LONGCORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	6851116338APP23	MI

General Provider Information

NPI Number	:	1194416818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY RENEE LONGCORE

Provider Business Mailing Address
First Line	:	1115 BALL AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 BALL AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5904
Country	:	US
Telephone Number	:	616-456-6571
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2023
Last Update Date	:	01/23/2026

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