Provider Demographics
NPI:1316303803
Name:MOELLER, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
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 1:15113 YOSEMITE WAY
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-6037
Mailing Address - Country:US
Mailing Address - Phone:408-710-7124
Mailing Address - Fax:
Practice Address - Street 1:290 IOOF AVE
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5204
Practice Address - Country:US
Practice Address - Phone:408-846-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91385106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist