Provider Demographics
NPI:1356645808
Name:MOELLER, AGATHA (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:AGATHA
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 N DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5030
Mailing Address - Country:US
Mailing Address - Phone:312-932-9163
Mailing Address - Fax:
Practice Address - Street 1:1230 N STATE PKWY
Practice Address - Street 2:#27C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2260
Practice Address - Country:US
Practice Address - Phone:312-932-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0063031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical