Provider Demographics
NPI:1730623174
Name:MOLLER, PENINA
Entity type:Individual
Prefix:
First Name:PENINA
Middle Name:
Last Name:MOLLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6716
Mailing Address - Country:US
Mailing Address - Phone:646-705-2651
Mailing Address - Fax:
Practice Address - Street 1:250 E 164TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-6201
Practice Address - Country:US
Practice Address - Phone:718-681-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-04
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022592-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist