Provider Demographics
NPI:1699325613
Name:MOELLER, MADISON (CF-SLP)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 INDEPENDENCE AVE SE APT 301
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-1546
Mailing Address - Country:US
Mailing Address - Phone:631-905-5540
Mailing Address - Fax:
Practice Address - Street 1:3400 BELTSVILLE RD
Practice Address - Street 2:
Practice Address - City:CALVERTON
Practice Address - State:MD
Practice Address - Zip Code:20705-3312
Practice Address - Country:US
Practice Address - Phone:631-905-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01940L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist