Healthcare Provider Details

I. General information

NPI: 1477067932
Provider Name (Legal Business Name): MICHELLE MARIE KILCOYNE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 ESTERO AVE
MORRO BAY CA
93442-2633
US

IV. Provider business mailing address

PO BOX 1004
SAN LUIS OBISPO CA
93406-1004
US

V. Phone/Fax

Practice location:
  • Phone: 805-550-8717
  • Fax:
Mailing address:
  • Phone: 805-550-8717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: