MEDICARE: MOLLY LAICH

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	101YM0800X	Mental Health Counselor
2	103T00000X	Psychologist	6362009449	MI
3	101YM0800X	Mental Health Counselor	LH61036510	WA

General Provider Information

NPI Number	:	1649748955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY LAICH

Provider Business Mailing Address
First Line	:	5524 ROWLEY BLVD
Second Line	:
City	:	WATERFORD TWP
State	:	MI
Zip	:	48329-3243
Country	:	US
Telephone Number	:	248-736-2989
Fax Number	:

Provider Business Practice Location Address
First Line	:	1134 N CAMPBELL RD APT 101
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-1537
Country	:	US
Telephone Number	:	253-833-7444
Fax Number	:

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

Provider Enumeration Date	:	11/05/2018
Last Update Date	:	10/27/2022

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Directions to “ MOLLY LAICH ” Practice Location

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