Healthcare Provider Details

I. General information

NPI: 1578647004
Provider Name (Legal Business Name): MICHAEL J MOLLER PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 6TH ST N 102
HUDSON WI
54016-7171
US

IV. Provider business mailing address

900 6TH ST N 102
HUDSON WI
54016-7171
US

V. Phone/Fax

Practice location:
  • Phone: 715-386-0856
  • Fax: 715-386-0948
Mailing address:
  • Phone: 715-386-0856
  • Fax: 715-386-0948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2320
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2320
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2320
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number2320
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number2320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: