Provider Demographics
NPI:1992184568
Name:MOELLER, LAURA (MS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1210
Mailing Address - Country:US
Mailing Address - Phone:260-424-7977
Mailing Address - Fax:260-426-7576
Practice Address - Street 1:2417 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1210
Practice Address - Country:US
Practice Address - Phone:260-424-7977
Practice Address - Fax:260-426-7576
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor