Provider Demographics
NPI:1346713294
Name:MORIARTY, KELLY (MS, LLPC, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MORIARTY
Suffix:
Gender:F
Credentials:MS, LLPC, ATC, CSCS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:STOBBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2950 W HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9329
Mailing Address - Country:US
Mailing Address - Phone:517-367-0670
Mailing Address - Fax:
Practice Address - Street 1:2950 W HOWELL RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-9329
Practice Address - Country:US
Practice Address - Phone:517-367-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010015812255A2300X
MI6451023168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer