Provider Demographics
NPI:1619473998
Name:MOELTER, ASHLIE
Entity Type:Individual
Prefix:
First Name:ASHLIE
Middle Name:
Last Name:MOELTER
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 1:6573 STATE ROAD 50
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-3645
Mailing Address - Country:US
Mailing Address - Phone:262-607-0364
Mailing Address - Fax:
Practice Address - Street 1:101 BROAD ST STE 201
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2061
Practice Address - Country:US
Practice Address - Phone:262-248-7942
Practice Address - Fax:262-248-1202
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3631101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional