Provider Demographics
NPI:1457564403
Name:MOLDENHAUER, TIM EDWARD (MS-CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:EDWARD
Last Name:MOLDENHAUER
Suffix:
Gender:M
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8080
Mailing Address - Street 2:410 DEWEY STREET
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-8080
Mailing Address - Country:US
Mailing Address - Phone:715-424-8500
Mailing Address - Fax:715-424-8502
Practice Address - Street 1:410 DEWEY ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4715
Practice Address - Country:US
Practice Address - Phone:715-424-8500
Practice Address - Fax:715-424-8502
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI607-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42714700Medicaid