Provider Demographics
NPI:1417254707
Name:MOULTON, MARY (OTR)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:2515 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-8316
Mailing Address - Country:US
Mailing Address - Phone:815-441-7910
Mailing Address - Fax:
Practice Address - Street 1:2515 14TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-8316
Practice Address - Country:US
Practice Address - Phone:815-441-7910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO280551225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist