Provider Demographics
NPI:1578268744
Name:MOULTON, ASHLI K
Entity Type:Individual
Prefix:
First Name:ASHLI
Middle Name:K
Last Name:MOULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 S HANSON AVE
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-5093
Mailing Address - Country:US
Mailing Address - Phone:208-716-9660
Mailing Address - Fax:
Practice Address - Street 1:131 S HANSON AVE
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-5093
Practice Address - Country:US
Practice Address - Phone:208-716-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist