Provider Demographics
NPI:1689400749
Name:MULLOY, CARLY ANN
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:MULLOY
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 1:215 CANFORD DR
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3802
Mailing Address - Country:US
Mailing Address - Phone:484-682-5806
Mailing Address - Fax:
Practice Address - Street 1:100 YEARSLEY MILL RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5593
Practice Address - Country:US
Practice Address - Phone:484-227-1439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC017553101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional