Provider Demographics
NPI:1962612457
Name:MOYLAN, KELLYANN
Entity type:Individual
Prefix:
First Name:KELLYANN
Middle Name:
Last Name:MOYLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 56TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3918
Mailing Address - Country:US
Mailing Address - Phone:916-214-5355
Mailing Address - Fax:
Practice Address - Street 1:1120 56TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3918
Practice Address - Country:US
Practice Address - Phone:916-214-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)