Healthcare Provider Details

I. General information

NPI: 1003513052
Provider Name (Legal Business Name): NELLIE MOUALEU PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 02/10/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 RAINBOW BLVD
KANSAS CITY KS
66160-8500
US

IV. Provider business mailing address

2108 LEXINGTON AVE APT O
KANSAS CITY MO
64124-1635
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-1300
  • Fax:
Mailing address:
  • Phone: 214-778-8628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: