Provider Demographics
NPI:1962972695
Name:MOLDENHAUER, RICHARD ALLEN (LADC, LPCC,LCADC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:MOLDENHAUER
Suffix:
Gender:M
Credentials:LADC, LPCC,LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8972 520TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-4887
Mailing Address - Country:US
Mailing Address - Phone:715-220-2078
Mailing Address - Fax:
Practice Address - Street 1:W8972 520TH AVE
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011-4887
Practice Address - Country:US
Practice Address - Phone:715-220-2078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00060101YM0800X
MN300047101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty