Provider Demographics
NPI:1407388655
Name:MALLOY, KEVIN (LAC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MALLOY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 VALLEY HEALTH PLZ
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3607
Mailing Address - Country:US
Mailing Address - Phone:201-986-5037
Mailing Address - Fax:201-265-5027
Practice Address - Street 1:610 VALLEY HEALTH PLZ
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3607
Practice Address - Country:US
Practice Address - Phone:201-986-5037
Practice Address - Fax:201-265-5027
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00688700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health