Healthcare Provider Details

I. General information

NPI: 1376948307
Provider Name (Legal Business Name): KEVIN MOELLER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 RANCHO SIRINGO RD APT 1
SANTA FE NM
87505-5530
US

IV. Provider business mailing address

2215 RANCHO SIRINGO RD APT 1
SANTA FE NM
87505-5530
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-8846
  • Fax:
Mailing address:
  • Phone: 505-670-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08789
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: