Provider Demographics
NPI:1003359761
Name:MOULTON, PATRICE ANTHIA (LPC)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:ANTHIA
Last Name:MOULTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 BENNETT CIR
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06120-1153
Mailing Address - Country:US
Mailing Address - Phone:860-985-0284
Mailing Address - Fax:
Practice Address - Street 1:3 NORTHWESTERN DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3465
Practice Address - Country:US
Practice Address - Phone:860-243-3477
Practice Address - Fax:860-243-3224
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X
CT3824101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health