Provider Demographics
NPI:1992000657
Name:MICHAEL J MOLLER PA
Entity Type:Organization
Organization Name:MICHAEL J MOLLER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP, ABPP
Authorized Official - Phone:715-386-0856
Mailing Address - Street 1:900 6TH ST N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7171
Mailing Address - Country:US
Mailing Address - Phone:715-386-0856
Mailing Address - Fax:715-386-0948
Practice Address - Street 1:900 6TH ST N
Practice Address - Street 2:SUITE 102
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7171
Practice Address - Country:US
Practice Address - Phone:715-386-0856
Practice Address - Fax:715-386-0948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2320-057103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TF0200X, 103TP0814X
MNLP3404103T00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0200X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN880824400Medicaid
WI39739300Medicaid
WI39739300Medicaid