Healthcare Provider Details

I. General information

NPI: 1164130100
Provider Name (Legal Business Name): GLEN ANTHONY MOELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 NATIONS DR STE 208
GURNEE IL
60031-9176
US

IV. Provider business mailing address

447 PARK LN
LAKE BLUFF IL
60044-2322
US

V. Phone/Fax

Practice location:
  • Phone: 847-625-9004
  • Fax: 847-625-9073
Mailing address:
  • Phone: 847-217-2460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.020406
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number101YM0800X
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: