Provider Demographics
NPI:1205907888
Name:MOLLOY, KEVIN PATRICK (MS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:MOLLOY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LINCOLN WAY EAST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2016
Mailing Address - Country:US
Mailing Address - Phone:574-255-4976
Mailing Address - Fax:574-255-1882
Practice Address - Street 1:113 LINCOLN WAY EAST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2016
Practice Address - Country:US
Practice Address - Phone:574-255-4976
Practice Address - Fax:574-255-1882
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002349A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health