Provider Demographics
NPI:1316542830
Name:CEDAR CREEK PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:CEDAR CREEK PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-348-8031
Mailing Address - Street 1:1235 OAK TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-6120
Mailing Address - Country:US
Mailing Address - Phone:260-348-8031
Mailing Address - Fax:
Practice Address - Street 1:1235 OAK TRAIL CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-6120
Practice Address - Country:US
Practice Address - Phone:260-348-8031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty