MEDICARE: MRS. MILDRED WILLIAMS MOLLER PT

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	PT24393	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT24393	OTHER	CA	PSYCHIATRIC TEHNICIAN

General Provider Information

NPI Number	:	1427239177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MILDRED WILLIAMS MOLLER PT

Provider Business Mailing Address
First Line	:	2804 ADELINE ST
Second Line	:	B
City	:	EMERYVILLE
State	:	CA
Zip	:	94608-4433
Country	:	US
Telephone Number	:	510-834-0516
Fax Number	:

Provider Business Practice Location Address
First Line	:	2804 ADELINE ST
Second Line	:	B
City	:	EMERYVILLE
State	:	CA
Zip	:	94608-4433
Country	:	US
Telephone Number	:	510-834-0516
Fax Number	:

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

Provider Enumeration Date	:	11/23/2007
Last Update Date	:	09/06/2023

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