Provider Demographics
NPI:1275790586
Name:MOULDER, DIANNE (MED, PC)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:
Last Name:MOULDER
Suffix:
Gender:F
Credentials:MED, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 W MAPLE ST
Mailing Address - Street 2:STE. 103
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2858
Mailing Address - Country:US
Mailing Address - Phone:330-966-8677
Mailing Address - Fax:330-966-6511
Practice Address - Street 1:1303 W MAPLE ST
Practice Address - Street 2:STE. 103
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2858
Practice Address - Country:US
Practice Address - Phone:330-966-8677
Practice Address - Fax:330-966-6511
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC5156101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor