Healthcare Provider Details

I. General information

NPI: 1194835231
Provider Name (Legal Business Name): MADELEINE B MOLLER L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 MAPLE RD
EASTON CT
06612-1033
US

IV. Provider business mailing address

260 MAPLE RD
EASTON CT
06612-1033
US

V. Phone/Fax

Practice location:
  • Phone: 203-838-7681
  • Fax: 203-838-7681
Mailing address:
  • Phone: 203-838-7681
  • Fax: 203-838-7681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004178
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: