Basic Information
| Provider Information | |||||||||
| NPI: | 1871752097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOULTON | ||||||||
| OtherFirstName: | K.K. | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5327 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741121411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188506728 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 231 E GRAHAM AVE | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743612436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188251405 | ||||||||
| FaxNumber: | 9188251406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.