Provider Demographics
NPI:1134571219
Name:VAN MOEN, KELLY (MS, LLPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VAN MOEN
Suffix:
Gender:F
Credentials:MS, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 W GATES ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-4494
Mailing Address - Country:US
Mailing Address - Phone:586-752-6969
Mailing Address - Fax:
Practice Address - Street 1:124 W GATES ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BRUCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48065-4494
Practice Address - Country:US
Practice Address - Phone:586-752-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015525101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)