Provider Demographics
NPI:1396814760
Name:MOULTON, PATRICIA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:MOULTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14795 JEFFREY ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-0416
Mailing Address - Country:US
Mailing Address - Phone:949-857-0193
Mailing Address - Fax:949-559-4590
Practice Address - Street 1:14795 JEFFREY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-0414
Practice Address - Country:US
Practice Address - Phone:949-857-0193
Practice Address - Fax:949-559-4590
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6743103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPMCP6743AMedicare ID - Type Unspecified