Provider Demographics
NPI:1861543084
Name:MOELLER, MARY P (PHD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:P
Last Name:MOELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:P
Other - Last Name:AULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:555 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2136
Mailing Address - Country:US
Mailing Address - Phone:402-280-8100
Mailing Address - Fax:402-280-8103
Practice Address - Street 1:425 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2100
Practice Address - Country:US
Practice Address - Phone:402-452-5000
Practice Address - Fax:402-452-5028
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE43231H00000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06606OtherBCBS BT
IA0586982Medicaid
IA3586982Medicaid
IA1586982Medicaid
NE100251703-00Medicaid
NE06610OtherBCBS ENT
NE100251704-00Medicaid
IA2586982Medicaid
NE100251704-00Medicaid