Provider Demographics
NPI:1114403243
Name:MOULDER, JOHN PAUL (MDIV, MA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:MOULDER
Suffix:
Gender:M
Credentials:MDIV, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2014
Mailing Address - Country:US
Mailing Address - Phone:312-787-8425
Mailing Address - Fax:
Practice Address - Street 1:126 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2014
Practice Address - Country:US
Practice Address - Phone:312-787-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor