Provider Demographics
NPI:1972524742
Name:MOELLER, THEODORE A (PH D)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:A
Last Name:MOELLER
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:T
Other - Middle Name:A
Other - Last Name:MOELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH D
Mailing Address - Street 1:400 N WOODLAWN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206
Mailing Address - Country:US
Mailing Address - Phone:316-686-5151
Mailing Address - Fax:316-652-2436
Practice Address - Street 1:400 N WOODLAWN
Practice Address - Street 2:SUITE 202
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206
Practice Address - Country:US
Practice Address - Phone:316-686-5151
Practice Address - Fax:316-652-2436
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R31946Medicare UPIN
KS022064Medicare ID - Type Unspecified