Healthcare Provider Details

I. General information

NPI: 1992000657
Provider Name (Legal Business Name): MICHAEL J MOLLER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

900 6TH ST N SUITE 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 Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number2320-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2320-057
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP3404
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2320-057
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3404
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2320-057
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2320-057
License Number StateWI
# 8
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP3404
License Number StateMN
# 9
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number2320-057
License Number StateWI
# 10
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number2320-057
License Number StateWI
# 11
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3404
License Number StateMN
# 12
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberLP3404
License Number StateMN
# 13
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number2320-057
License Number StateWI
# 14
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License NumberLP3404
License Number StateMN
# 15
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2320-057
License Number StateWI

VIII. Authorized Official

Name: DR. MICHAEL J MOLLER
Title or Position: OWNER
Credential: PSYD, LP, ABPP
Phone: 715-386-0856