Provider Demographics
NPI:1811444573
Name:MOORE, MOLLIE NICOLE (PHD)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:NICOLE
Other - Last Name:GRADEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7102 MINERAL POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717
Practice Address - Country:US
Practice Address - Phone:608-828-7611
Practice Address - Fax:608-828-7656
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3722-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist