MEDICARE: SHELLEY ELAINE MOELLER LICSW

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	1041C0700X	Clinical Social Worker	1026602	MA

General Provider Information

NPI Number	:	1467519595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY ELAINE MOELLER LICSW

Provider Business Mailing Address
First Line	:	217 FOLLEN RD
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02421-5802
Country	:	US
Telephone Number	:	781-652-8884
Fax Number	:

Provider Business Practice Location Address
First Line	:	76 BEDFORD ST STE 21
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420-4641
Country	:	US
Telephone Number	:	781-652-8884
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/01/2007
Last Update Date	:	07/09/2007

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