MEDICARE: LAURA MOELLER MS

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1992184568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA MOELLER MS

Provider Business Mailing Address
First Line	:	2417 FAIRFIELD AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-1210
Country	:	US
Telephone Number	:	260-424-7977
Fax Number	:	260-426-7576

Provider Business Practice Location Address
First Line	:	2417 FAIRFIELD AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-1210
Country	:	US
Telephone Number	:	260-424-7977
Fax Number	:	260-426-7576

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

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	05/28/2015

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Directions to “ LAURA MOELLER MS” Practice Location

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