Provider Demographics
NPI:1417218975
Name:MOULTON, YVETTE (LCPC)
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-1229
Mailing Address - Country:US
Mailing Address - Phone:443-500-0258
Mailing Address - Fax:
Practice Address - Street 1:3911 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-1229
Practice Address - Country:US
Practice Address - Phone:443-500-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6342101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional