=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548817406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRIAM DENISE MOELLER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2019
-----------------------------------------------------
Last Update Date | 07/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3517 CAMINO DEL RIO S # S407
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-955-8906
-----------------------------------------------------
Fax | 619-955-8906
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3002 ARMSTRONG ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92111-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-633-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------