Provider Demographics
NPI:1972615219
Name:MOLLER, MARY PAUL (LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PAUL
Last Name:MOLLER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 HOSPITAL WAY BLDG D
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2763
Mailing Address - Country:US
Mailing Address - Phone:208-233-3353
Mailing Address - Fax:208-233-1923
Practice Address - Street 1:1151 HOSPITAL WAY BLDG D
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2763
Practice Address - Country:US
Practice Address - Phone:208-233-3353
Practice Address - Fax:208-233-1923
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-204101YM0800X
IDLMFT-3003106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist