Provider Demographics
NPI:1083126866
Name:MOULTON, KONNIESHA M (LMFT)
Entity Type:Individual
Prefix:MS
First Name:KONNIESHA
Middle Name:M
Last Name:MOULTON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3225
Mailing Address - Country:US
Mailing Address - Phone:862-621-0833
Mailing Address - Fax:
Practice Address - Street 1:622-624 VALLEY RD STE 6D
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1462
Practice Address - Country:US
Practice Address - Phone:862-621-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FI00177900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist