Healthcare Provider Details

I. General information

NPI: 1235745522
Provider Name (Legal Business Name): COLIN THOMAS MOYLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

311 MORRISON ST APT 14
BIG RAPIDS MI
49307-2223
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax:
Mailing address:
  • Phone: 989-578-2976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: