Healthcare Provider Details

I. General information

NPI: 1508592080
Provider Name (Legal Business Name): MATTHEW MOELLER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 MAIN ST STE 1
BUZZARDS BAY MA
02532-3285
US

IV. Provider business mailing address

243 MAIN ST STE 1
BUZZARDS BAY MA
02532-3285
US

V. Phone/Fax

Practice location:
  • Phone: 508-743-5542
  • Fax:
Mailing address:
  • Phone: 508-743-5542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025038678
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number176152
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: