Provider Demographics
NPI:1952907230
Name:MOLINE, NATHAN DAVID
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:DAVID
Last Name:MOLINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-2041
Mailing Address - Country:US
Mailing Address - Phone:641-236-1644
Mailing Address - Fax:
Practice Address - Street 1:818 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-2041
Practice Address - Country:US
Practice Address - Phone:641-236-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health