Healthcare Provider Details

I. General information

NPI: 1285373761
Provider Name (Legal Business Name): MAX MOYLAN LLMSW - CLINICAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21500 HAGGERTY RD STE 350
NORTHVILLE MI
48167-8992
US

IV. Provider business mailing address

21500 HAGGERTY RD STE 350
NORTHVILLE MI
48167-8992
US

V. Phone/Fax

Practice location:
  • Phone: 734-265-0841
  • Fax:
Mailing address:
  • Phone: 734-265-0841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851115023
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: