Provider Demographics
NPI:1619079886
Name:MOULTON, M. LISE (LISW)
Entity Type:Individual
Prefix:MS
First Name:M.
Middle Name:LISE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:216-479-5541
Mailing Address - Fax:216-479-5554
Practice Address - Street 1:5105 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4203
Practice Address - Country:US
Practice Address - Phone:216-621-5600
Practice Address - Fax:216-479-5554
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0004208104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker