Provider Demographics
NPI:1528190592
Name:MOELLER, FRED T (LPC)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:T
Last Name:MOELLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11805 NORTHFALL LANE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009
Mailing Address - Country:US
Mailing Address - Phone:770-410-5788
Mailing Address - Fax:770-410-4041
Practice Address - Street 1:11805 NORTHFALL LANE
Practice Address - Street 2:SUITE 804
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009
Practice Address - Country:US
Practice Address - Phone:770-410-5788
Practice Address - Fax:770-410-4041
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2084101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA241087000OtherMAGELLAN BEHAVIORAL HEALT
GA324771962AMedicaid