MEDICARE: GLEN ANTHONY MOELLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	178.020406	IL
2	103TC0700X	Clinical Psychologist	101YM0800X	IL

General Provider Information

NPI Number	:	1164130100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN ANTHONY MOELLER

Provider Business Mailing Address
First Line	:	447 PARK LN
Second Line	:
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-2322
Country	:	US
Telephone Number	:	847-217-2460
Fax Number	:

Provider Business Practice Location Address
First Line	:	1790 NATIONS DR STE 208
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-9176
Country	:	US
Telephone Number	:	847-625-9004
Fax Number	:	847-625-9073

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2022
Last Update Date	:	07/31/2024

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Directions to “ GLEN ANTHONY MOELLER ” Practice Location

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