Provider Demographics
NPI:1659678365
Name:MOULTON, BRYAN RICHARD (LPC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:RICHARD
Last Name:MOULTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E 300 N
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1228
Mailing Address - Country:US
Mailing Address - Phone:435-851-6733
Mailing Address - Fax:
Practice Address - Street 1:240 E 300 N
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1228
Practice Address - Country:US
Practice Address - Phone:435-851-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6200010-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional