Provider Demographics
NPI:1720101926
Name:MOLDAUER, LANNING (PHD)
Entity Type:Individual
Prefix:DR
First Name:LANNING
Middle Name:
Last Name:MOLDAUER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 33RD ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-1630
Mailing Address - Country:US
Mailing Address - Phone:202-244-5293
Mailing Address - Fax:202-318-2328
Practice Address - Street 1:5619 33RD ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-1630
Practice Address - Country:US
Practice Address - Phone:202-244-5293
Practice Address - Fax:202-318-2328
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1348103T00000X
MD1700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCR56588Medicare UPIN