Basic Information
| Provider Information | |||||||||
| NPI: | 1770582884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOLLER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | PROF. | ||||||||
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| Credential: | DNP, APRN, PMHCNS-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 STEVENSON RD | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065152471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037475667 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 08/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | AP30003075 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 364SP0809X | 004003 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 004003 | 01 | CT | APRN LICENSE | OTHER | AP30003075 | 01 | WA | ARNP LIC # | OTHER |