Provider Demographics
NPI:1093119679
Name:MOULTON, DONNA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MIZE ST
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-3346
Mailing Address - Country:US
Mailing Address - Phone:706-639-5634
Mailing Address - Fax:
Practice Address - Street 1:501 MIZE ST
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-3346
Practice Address - Country:US
Practice Address - Phone:706-639-5634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0064631041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator