Provider Demographics
NPI:1285373761
Name:MOYLAN, MAX (LLMSW - CLINICAL)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:
Last Name:MOYLAN
Suffix:
Gender:M
Credentials:LLMSW - CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 N ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3630
Mailing Address - Country:US
Mailing Address - Phone:248-914-6759
Mailing Address - Fax:
Practice Address - Street 1:26711 WOODWARD AVE STE 208
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1368
Practice Address - Country:US
Practice Address - Phone:248-703-4920
Practice Address - Fax:248-629-9551
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511150231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6851115023OtherLIMITED LICENSE NUMBER