Provider Demographics
NPI:1063776870
Name:MOELLENDORF, CARLA (DTV)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:
Last Name:MOELLENDORF
Suffix:
Gender:F
Credentials:DTV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 FARGO BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2978
Mailing Address - Country:US
Mailing Address - Phone:630-947-4144
Mailing Address - Fax:630-402-0789
Practice Address - Street 1:1555 FARGO BLVD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2978
Practice Address - Country:US
Practice Address - Phone:630-947-4144
Practice Address - Fax:630-402-0789
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist