Provider Demographics
NPI:1215904537
Name:MOELLER, ROBIN BETH (LCSW)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:BETH
Last Name:MOELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 GAINSBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2871
Mailing Address - Country:US
Mailing Address - Phone:631-662-5700
Mailing Address - Fax:
Practice Address - Street 1:16 GAINSBOROUGH RD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2871
Practice Address - Country:US
Practice Address - Phone:631-662-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0512081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02560185Medicaid
NYN576E1Medicare ID - Type Unspecified