Healthcare Provider Details

I. General information

NPI: 1134328420
Provider Name (Legal Business Name): DAVID R. MOUILLE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4786 BLACK SWAN DR
SHAWNEE KS
66216-1235
US

IV. Provider business mailing address

4786 BLACK SWAN DR
SHAWNEE KS
66216-1235
US

V. Phone/Fax

Practice location:
  • Phone: 913-962-6810
  • Fax: 913-962-6810
Mailing address:
  • Phone: 913-962-6810
  • Fax: 913-962-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number794
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPYRO327
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number794
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPYRO327
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number794
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPYRO327
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number794
License Number StateKS
# 8
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPYRO327
License Number StateMO
# 9
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number794
License Number StateKS
# 10
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPYRO327
License Number StateMO
# 11
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number794
License Number StateKS
# 12
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPYRO327
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: