Provider Demographics
NPI:1134996465
Name:MOELLER, JUSTIN M (LMT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:MOELLER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3234 CENTRALIA ALPHA RD
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WA
Mailing Address - Zip Code:98570-9610
Mailing Address - Country:US
Mailing Address - Phone:360-269-7346
Mailing Address - Fax:
Practice Address - Street 1:403 N MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2627
Practice Address - Country:US
Practice Address - Phone:360-269-7346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61317965225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist