Provider Demographics
NPI:1578647004
Name:MOLLER, MICHAEL J (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MOLLER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 6TH ST N
Mailing Address - Street 2:102
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7171
Mailing Address - Country:US
Mailing Address - Phone:715-386-0856
Mailing Address - Fax:715-386-0948
Practice Address - Street 1:900 6TH ST N
Practice Address - Street 2:102
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7171
Practice Address - Country:US
Practice Address - Phone:715-386-0856
Practice Address - Fax:715-386-0948
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2320103T00000X, 103TC0700X, 103TC2200X, 103TF0000X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2172193OtherCOMPSYCH
WI39739300OtherWISCONSIN MEDICAL ASSISTANCE
MN431R2MOOtherBCBS
WISSN001OtherANTHEM BLUE CROSS OF WI
20558-03OtherBEHAVIOR HEALTH PROVIDERS
MN439K4MOOtherBCBS
MN036J4MOOtherBCBS MN PRO FEE
WI39739300Medicaid
WI61-74465OtherUBH
MN880824400Medicaid
MNHP20346OtherHEALTHPARTNERS
MN61-74465OtherMEDICA / UBH
MNNA9031027526OtherPREFERRED ONE
WI01413OtherGROUP HEALTH
1202109 16675OtherMAGELLEN
01413OtherCOMPCARE
115830OtherUCARE
SSNOtherHEALTHNET / TRICARE
WIP33335Medicare UPIN
WI004880086Medicare ID - Type Unspecified