Provider Demographics
NPI:1124379466
Name:MOULTON, RUSHAWN ANTHONY
Entity Type:Individual
Prefix:MR
First Name:RUSHAWN
Middle Name:ANTHONY
Last Name:MOULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 VIA LATA
Mailing Address - Street 2:300
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3978
Mailing Address - Country:US
Mailing Address - Phone:909-433-0445
Mailing Address - Fax:
Practice Address - Street 1:790 VIA LATA
Practice Address - Street 2:300
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3978
Practice Address - Country:US
Practice Address - Phone:909-433-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health