Basic Information
Provider Information | |||||||||
NPI: | 1720532211 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOULD | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EUSTIS | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | SUE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1940 HARRISON AVENUE | ||||||||
Address2: | EMERALD COAST BEHAVIORAL HOSPITAL | ||||||||
City: | PANAMA CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 324056755 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8507630017 | ||||||||
FaxNumber: | 8507634248 | ||||||||
Practice Location | |||||||||
Address1: | 340 MAGNOLIA CIR | ||||||||
Address2: |   | ||||||||
City: | TYNDALL AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 324035604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502837511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2016 | ||||||||
LastUpdateDate: | 07/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW12778 | FL | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.