1578647004 NPI number — MICHAEL J MOLLER PSYD

Table of content: MICHAEL J MOLLER PSYD (NPI 1578647004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578647004 NPI number — MICHAEL J MOLLER PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLLER
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578647004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 6TH ST N
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54016-7171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-386-0856
Provider Business Mailing Address Fax Number:
715-386-0948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 6TH ST N
Provider Second Line Business Practice Location Address:
102
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54016-7171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-386-0856
Provider Business Practice Location Address Fax Number:
715-386-0948
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2320 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 2320 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC2200X , with the licence number: 2320 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0000X , with the licence number: 2320 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: 2320 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2172193 . This is a "COMPSYCH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39739300 . This is a "WISCONSIN MEDICAL ASSISTANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 431R2MO . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: SSN001 . This is a "ANTHEM BLUE CROSS OF WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 20558-03 . This is a "BEHAVIOR HEALTH PROVIDERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 439K4MO . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 036J4MO . This is a "BCBS MN PRO FEE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 39739300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61-74465 . This is a "UBH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 880824400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP20346 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 61-74465 . This is a "MEDICA / UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NA9031027526 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01413 . This is a "GROUP HEALTH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1202109 16675 . This is a "MAGELLEN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01413 . This is a "COMPCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 115830 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: SSN . This is a "HEALTHNET / TRICARE" identifier . This identifiers is of the category "OTHER".




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