MEDICARE: CEDAR CREEK PSYCHOLOGICAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1316542830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR CREEK PSYCHOLOGICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	1235 OAK TRAIL CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-6120
Country	:	US
Telephone Number	:	260-348-8031
Fax Number	:

Provider Business Practice Location Address
First Line	:	1235 OAK TRAIL CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-6120
Country	:	US
Telephone Number	:	260-348-8031
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW ROBERT MOELLER
Credential	:
Telephone Number	:	260-348-8031

Provider Enumeration Date	:	12/02/2020
Last Update Date	:	12/02/2020

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