Provider Demographics
NPI:1609090745
Name:MOEHLE, SHARON (ED,S)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:MOEHLE
Suffix:
Gender:F
Credentials:ED,S
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:
Other - Last Name:MOEHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:266 LAMP AND LANTERN VLG
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8209
Mailing Address - Country:US
Mailing Address - Phone:636-227-4949
Mailing Address - Fax:636-779-1456
Practice Address - Street 1:266 LAMP AND LANTERN VLG
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-8209
Practice Address - Country:US
Practice Address - Phone:636-227-4949
Practice Address - Fax:636-779-1456
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY0178103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDX5960OtherBLUE CROSS
ID805997100Medicaid
ID000010003974OtherREGENCE
ID481086633OtherTAX IDENTIFICATON
ID260048265Medicare ID - Type UnspecifiedRAILROAD MEDICARE
ID805997100Medicaid