=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558946913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE ROONEY LCADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2021
-----------------------------------------------------
Last Update Date | 03/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 WHITE HORSE RD STE C101
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-805-7751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 346 HEATHER DR N
-----------------------------------------------------
City | MANTUA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08051-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-318-6082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 37LC00326600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------