Provider Demographics
NPI:1124113758
Name:MOLLER, WALTER ANTON (LMP)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:ANTON
Last Name:MOLLER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 11381
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110
Mailing Address - Country:US
Mailing Address - Phone:360-620-4046
Mailing Address - Fax:360-782-1625
Practice Address - Street 1:702 LEBO BLVD.
Practice Address - Street 2:SUITE D
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310
Practice Address - Country:US
Practice Address - Phone:360-620-4046
Practice Address - Fax:360-782-1625
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014895225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist