Provider Demographics
NPI:1689423188
Name:MOELLER, MAGGIE ELISE (DO)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:ELISE
Last Name:MOELLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 W BELMONT AVE APT 408
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7384
Mailing Address - Country:US
Mailing Address - Phone:630-880-7377
Mailing Address - Fax:
Practice Address - Street 1:3509 N NORTH AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647
Practice Address - Country:US
Practice Address - Phone:630-880-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics