Healthcare Provider Details

I. General information

NPI: 1407388655
Provider Name (Legal Business Name): KEVIN MALLOY L.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 VALLEY HEALTH PLZ
PARAMUS NJ
07652-3607
US

IV. Provider business mailing address

610 VALLEY HEALTH PLZ
PARAMUS NJ
07652-3607
US

V. Phone/Fax

Practice location:
  • Phone: 201-986-5037
  • Fax: 201-265-5027
Mailing address:
  • Phone: 201-986-5037
  • Fax: 201-265-5027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00688700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: