Healthcare Provider Details

I. General information

NPI: 1396996484
Provider Name (Legal Business Name): LILLIAN M. MOELLER, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BOULDER CRESCENT ST STE 101B
COLORADO SPRINGS CO
80903-3344
US

IV. Provider business mailing address

10 BOULDER CRESCENT ST STE 101B
COLORADO SPRINGS CO
80903-3344
US

V. Phone/Fax

Practice location:
  • Phone: 719-442-6955
  • Fax: 719-442-6947
Mailing address:
  • Phone: 719-442-6955
  • Fax: 719-442-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1558
License Number StateCO

VIII. Authorized Official

Name: LILLIAN M. MOELLER
Title or Position: OWNER
Credential: PH.D.
Phone: 719-442-6955