Provider Demographics
NPI:1376948307
Name:MOELLER, KEVIN (LMSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MOELLER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 RANCHO SIRINGO RD APT 1
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5530
Mailing Address - Country:US
Mailing Address - Phone:505-670-8846
Mailing Address - Fax:
Practice Address - Street 1:2215 RANCHO SIRINGO RD APT 1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5530
Practice Address - Country:US
Practice Address - Phone:505-670-8846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-087891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical