Provider Demographics
NPI:1215096904
Name:MOELLER, LILLIAN M (PHD)
Entity type:Individual
Prefix:DR
First Name:LILLIAN
Middle Name:M
Last Name:MOELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BOULDER CRESCENT ST STE 101B
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3344
Mailing Address - Country:US
Mailing Address - Phone:719-442-6955
Mailing Address - Fax:719-442-6947
Practice Address - Street 1:10 BOULDER CRESCENT ST STE 101B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3344
Practice Address - Country:US
Practice Address - Phone:719-442-6955
Practice Address - Fax:719-442-6947
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1558103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COR14631Medicare UPIN
COCO41446Medicare PIN