Provider Demographics
NPI:1770184954
Name:MOELLER, MICHELLE ANN (CMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:MOELLER
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5648 OAK GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1243
Mailing Address - Country:US
Mailing Address - Phone:314-566-2229
Mailing Address - Fax:
Practice Address - Street 1:5648 OAK GROVE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1243
Practice Address - Country:US
Practice Address - Phone:314-566-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73260225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist