Provider Demographics
NPI:1295262053
Name:MOELLER, JOHANNA (MA, CF-SLP)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8703 HIGHWAY 17 BYPASS S
Mailing Address - Street 2:SUITE I
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575
Mailing Address - Country:US
Mailing Address - Phone:843-457-1053
Mailing Address - Fax:843-215-2910
Practice Address - Street 1:8703 HIGHWAY 17 BYPASS S
Practice Address - Street 2:SUITE I
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575
Practice Address - Country:US
Practice Address - Phone:843-457-1053
Practice Address - Fax:843-215-2910
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSLP.6224.SPIN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist