Basic Information
| Provider Information | |||||||||
| NPI: | 1144532052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARIAS-MOELLER | ||||||||
| FirstName: | RAQUEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663464 | ||||||||
| FaxNumber: | 4142663466 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663464 | ||||||||
| FaxNumber: | 4142663466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | CS1600480 | DC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | 67359 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1144532052 | 05 | WI | MEDICAID |