Provider Demographics
NPI:1053345777
Name:MOELLER, CHARLES RICHARD (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:MOELLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 MIDDLE SETTLEMENT RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-5317
Mailing Address - Country:US
Mailing Address - Phone:315-724-2845
Mailing Address - Fax:315-797-3667
Practice Address - Street 1:4301 MIDDLE SETTLEMENT RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-5317
Practice Address - Country:US
Practice Address - Phone:315-724-2845
Practice Address - Fax:315-797-3667
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007627103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51854BMedicare ID - Type Unspecified