Provider Demographics
NPI:1770539827
Name:MOLLERUD, THEODORE E
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:E
Last Name:MOLLERUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E CLAIREMONT AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4772
Mailing Address - Country:US
Mailing Address - Phone:715-831-0289
Mailing Address - Fax:715-831-4722
Practice Address - Street 1:2215 E CLAIREMONT AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4772
Practice Address - Country:US
Practice Address - Phone:715-831-0289
Practice Address - Fax:715-831-4722
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42813100Medicaid