Basic Information
| Provider Information | |||||||||
| NPI: | 1144820382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | HART | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | 14303-RAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 S BEACON ST | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907314324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105144940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 132 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907313702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105144940 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2020 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 14303-RAC | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.