Provider Demographics
NPI:1659482644
Name:MOULTRUP, DAVID J (LICSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:MOULTRUP
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-3924
Mailing Address - Country:US
Mailing Address - Phone:617-484-1010
Mailing Address - Fax:
Practice Address - Street 1:5 WATSON RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-3924
Practice Address - Country:US
Practice Address - Phone:617-484-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1017921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical