Provider Demographics
NPI:1770676173
Name:MOELLER, AMY J (LICSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:MOELLER
Suffix:
Gender:F
Credentials:LICSW
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2910 CENTRE POINTE DRIVE
Mailing Address - Street 2:35 121A CHILDRENS HEALTH CARE
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2109
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:2425 CHICAGO AVENUE SOUTH
Practice Address - Street 2:CHILDRENS PRIMARY CLINIC TAMS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-813-6125
Practice Address - Fax:612-872-2338
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN00911104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical