Provider Demographics
NPI:1952704587
Name:MOLER, TAMARA (LAC)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MOLER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:1309 N DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-5704
Mailing Address - Country:US
Mailing Address - Phone:316-283-7829
Mailing Address - Fax:316-283-7449
Practice Address - Street 1:130 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-2206
Practice Address - Country:US
Practice Address - Phone:316-283-6743
Practice Address - Fax:316-283-6830
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS766101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100106710 BMedicaid
KS100106710 CMedicaid