Provider Demographics
NPI:1083950786
Name:MOULDER, MARYALICE (PTA)
Entity Type:Individual
Prefix:
First Name:MARYALICE
Middle Name:
Last Name:MOULDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37513 BAY HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-1584
Mailing Address - Country:US
Mailing Address - Phone:302-367-6699
Mailing Address - Fax:
Practice Address - Street 1:37513 BAY HARBOR DR
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-1584
Practice Address - Country:US
Practice Address - Phone:302-367-6699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000142225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant