Provider Demographics
NPI:1053182428
Name:MOELLER, CHRISTOPHER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:MOELLER
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:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:GILA
Mailing Address - State:NM
Mailing Address - Zip Code:88038-0454
Mailing Address - Country:US
Mailing Address - Phone:505-240-3804
Mailing Address - Fax:
Practice Address - Street 1:61 BUMPY RD
Practice Address - Street 2:
Practice Address - City:GILA
Practice Address - State:NM
Practice Address - Zip Code:88038-9516
Practice Address - Country:US
Practice Address - Phone:505-240-3804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099298891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical