Basic Information
| Provider Information | |||||||||
| NPI: | 1720118151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1939 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032336141 | ||||||||
| FaxNumber: | 5032332889 | ||||||||
| Practice Location | |||||||||
| Address1: | 1939 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032336141 | ||||||||
| FaxNumber: | 5032332889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 237600000X | 20586 | OR | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 212936 | 05 | OR | MEDICAID | 2432417000 | 01 | FEDERAL WORKERS COMP | OTHER | 9178104 | 05 | WA | MEDICAID | 0054627 | 01 | WA | WA WORKERS COMP | OTHER |