Healthcare Provider Details

I. General information

NPI: 1194136416
Provider Name (Legal Business Name): KELLY MOYLAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 6TH AVE STE 406
NEW YORK NY
10011-8409
US

IV. Provider business mailing address

300 LINDEN AVE
GLEN RIDGE NJ
07028-1110
US

V. Phone/Fax

Practice location:
  • Phone: 212-252-2112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078020-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: