Provider Demographics
NPI:1174043392
Name:MOELLER, KRIS A (OTR)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:A
Last Name:MOELLER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KRIS
Other - Middle Name:A
Other - Last Name:EICHSTAEDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:317 KNUTSON DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1133
Mailing Address - Country:US
Mailing Address - Phone:608-301-9378
Mailing Address - Fax:608-301-9388
Practice Address - Street 1:317 KNUTSON DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1133
Practice Address - Country:US
Practice Address - Phone:608-301-9378
Practice Address - Fax:608-301-9388
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3720-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40849300Medicaid