Provider Demographics
NPI:1790199164
Name:MOULTON, THERESA M (LMT)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:MOULTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SUNSET AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-4806
Mailing Address - Country:US
Mailing Address - Phone:224-730-9331
Mailing Address - Fax:
Practice Address - Street 1:1400 SUNSET AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-4806
Practice Address - Country:US
Practice Address - Phone:224-730-9331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227-013352174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist