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General NPI Number Information
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NPI Number | 1194136416
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Entity Type | Individual
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Provider Name | KELLY MOYLAN LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/09/2014
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Last Update Date | 05/09/2014
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Provider Practice Location Address
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Address Line | 412 6TH AVE STE 406
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City | NEW YORK
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State | NY
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Zip | 10011-8409
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Country | US
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Telephone | 212-252-2112
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Fax |
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Provider Business Mailing Address
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Address Line | 300 LINDEN AVE
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City | GLEN RIDGE
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State | NJ
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Zip | 07028-1110
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 078020-1
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License Number State | NY
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