Provider Demographics
NPI:1891392106
Name:MOELLER, KIMBERLY SUE (LICSW, LADC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:MOELLER
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29961 KEEPER RD
Mailing Address - Street 2:
Mailing Address - City:CHATFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55923-4831
Mailing Address - Country:US
Mailing Address - Phone:507-259-6258
Mailing Address - Fax:
Practice Address - Street 1:111 E RIVERFRONT ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-556-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301844101YA0400X
MN277741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty