Provider Demographics
NPI:1104119247
Name:MOELLER, KEISHA (BCBA)
Entity type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2707
Mailing Address - Country:US
Mailing Address - Phone:818-216-2764
Mailing Address - Fax:
Practice Address - Street 1:1509 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2707
Practice Address - Country:US
Practice Address - Phone:818-216-2764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF66160106H00000X
CA1-11-9368103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist