Healthcare Provider Details

I. General information

NPI: 1205907888
Provider Name (Legal Business Name): KEVIN PATRICK MOLLOY MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LINCOLN WAY EAST
MISHAWAKA IN
46544-2016
US

IV. Provider business mailing address

113 LINCOLN WAY EAST
MISHAWAKA IN
46544-2016
US

V. Phone/Fax

Practice location:
  • Phone: 574-255-4976
  • Fax: 574-255-1882
Mailing address:
  • Phone: 574-255-4976
  • Fax: 574-255-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002349A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: