Provider Demographics
NPI:1447425756
Name:MOELLER, DEBRA MARSICO
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:MARSICO
Last Name:MOELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 TURKEY TROTT TRL
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-5818
Mailing Address - Country:US
Mailing Address - Phone:912-727-2279
Mailing Address - Fax:912-727-2279
Practice Address - Street 1:739 TURKEY TROTT TRL
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-5818
Practice Address - Country:US
Practice Address - Phone:912-727-2279
Practice Address - Fax:912-727-2279
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA401046937AMedicaid